Janet E. Fischel, Ph.D.
There are several unique and exciting features of the clerkship setting that provide a rich opportunity for both teaching and learning. Virtually all students in the pediatric clerkship are motivated and interested; virtually all teachers are engaged in an aspect of medicine they have self-selected and enjoy. A carefully considered curriculum is at hand to guide both students and teachers. The students are briefed on our expectations for knowledge expansion, skill acquisition, and growth in important professional attitudes. The real world, composed of real patient problems and real mysteries provides a substantial data base for learning. The clerkship director has endeavored to establish a balance of meaningful experiences for the student--no small feat in a finite period of time. Yet none of these facts necessarily guarantees a successful educational experience. In fact, in order to maximize the learning opportunities for students and cultivate dedicated and skillful teachers, we should examine more broadly what teaching and learning are all about in the clerkship setting.
Teaching in the Clerkship Setting
Even the most traditional of clerkship structures can involve a broad variety of teaching techniques. The very fact that there is a curriculum to be "taught" promotes a formal, structured and mission-directed atmosphere for the clerkship. Those schools using oral and written examinations to sample what the student has learned and student presentations of patients in the formal rounding and report arenas each involve long-standing traditions of formal teaching and formal evaluative strategies.
On the other hand, clerkship sites also involve highly individualized, informal, and often opportunistic teaching techniques. The one-to-one preceptorship or apprenticeship model continues to be celebrated for its unique ability to entwine students in the practitioner's role as well as the clinical subject matter at hand. However briefly or extensively the apprenticeship model is used, it unifies the roles of model and teacher. The bottom line is that the teacher wears several hats. He or she can be formal at times, informal at others, standardized, structured, directing, non-directive, opportunistic, reflective. The clerkship is the teacher's classroom, but the walls, meeting schedule, audiovisual aids, visiting speakers and topics are not so easily defined or delineated.
Learning in the Clerkship Setting
Learning in the clerkship setting is no more unidimensional than is teaching. The clerkship does not represent a singular learning environment, nor does any one student have a singular learning style. In fact, as the learner grows in knowledge, skill, and attitudes, the ability to assimilate new and more complex information changes dramatically. To further complicate the picture, learning is not necessarily derived from those we usually identify as the teachers. There are books, computer programs, and self-instruction sources to serve as resources for learning above and beyond the clerkship teachers. Ultimately, a most important resource for learning in the clinical clerkship is the patient. Learning from one's patients, when artfully mediated by teachers, who both promote autonomy and model the attitudes and skills required for upgrading student competence, is likely the most rewarding form of learning in medicine.
Teaching and Learning in Context
The truest challenge of the clerkship year is less tangible than one might like, but critically important none-the-less. It is the building of the core knowledge to assure that we spark in the learner a self-propelled interest in lifelong and self-directed learning. Achieving that goal is neither a function of some instructional cookbook nor guaranteed by a specific curriculum, an exquisite patient mix, or a perfect evaluation method. These variables combine with teachers, guides, facilitators, role models and a good deal of autonomous discovery for a successful learning experience.
As the reader is no doubt aware, some of the more popular approaches in medical education these days are attempting to capture the importance of a very active and participatory learning context at the level of clinical clerk. Hand in hand with this trend, we are revisiting and critically reviewing the extent to which we need formal didactic lecturing, if at all. Among other sources, a major impetus for medical educational reform in this direction is embodied in the Association of American Medical Colleges' Acme-Tri Report1. The educational strategies identified therein have already surfaced in this discussion: 1) specify what students should learn (e.g., a curriculum as guide) and the skills and attitudes they should develop, 2)foster self-directed and lifelong learning skills, 3) decrease the use of lectures, and 4) develop skills for information management.
The trend embodied in these four strategies and delineated by the Acme-Tri Report, has scaffolded the teacher-student interaction in this era of medical educational reform to a more fully active, bi-directional, and perhaps even transactional educational process. The term, transactional process, is one borrowed from Samaroff and Chandler's2 model of the environmental and caretaker interactions in infant development, wherein I influence you, you are both active and reactive in influencing me in return, and the changed me influences the modified you. It is the transactions of infant, caretaker and environment which bring development to each next step. In the analogy posed here, the teacher is facilitator, inquirer, and information organizer; the student is investigator, identifier of information needed to problem solve, and information organizer as well. The student reflects back to the teacher what the student believes has been learned or solved or discovered, which is by no means necessarily the ultimate diagnosis. The teacher inquires some more, gives feedback, challenges assumptions, questions the thought path, pushes to expand the case, the principle or the concept to a broader level of application.
Although articulated in many different ways, the characteristic interactions just described include many pertinent features of problem-based learning and small group interactive learning as well as significant characteristics of celebrated clinical teachers3. In fact, Irby suggests that the more we learn about what our learners do and do not know (our "knowledge of learner"), the more effective we are as teachers, and the more effectively we can find the learners' difficulties. This is a wonderfully simple principle, but its simplicity is deceptive; as Irby points out, on any given ward team, there are learners at vastly different levels, and the learners have diverse needs. Further, there is rarely more than a single teacher (attending, preceptor or consultant) in a single such interaction, and it often takes some time to identify where the learners are in their analytic capability and in their knowledge stream.
This newer perspective on undergraduate medical education in the clerkship context has spurred a good deal of creativity. Space does not permit explanation of each theoretical construct or practical leaning strategy, but mention should be made of at least a cluster of the most popular themes, strategies and constructs:
Problem-based learning is a term which refers to the primacy of a problem which leads the learning process. For excellent reviews on the pros and cons of problem based learning see references 4,5 and 6. Learning emerges or results from the work and thought involved in resolving a problem. A key concept here is that a problem is proposed at first, and efforts to understand the problem and its solutions follow. There are variants of this model (case-based learning, patient-centered learning); each has at its core the importance of a clinical problem introduced at the start of the learning process. A central concept to self-directed learning is that the learner participates in defining what needs to be learned, plans and executes the tasks necessary for learning to occur, and participates in evaluation. Mann5 provides an excellent discussion of self-direction in medical education.
Problem-based learning opportunities may emerge from patient encounters or may be an exercise of the clerkship and organized in small group sessions with a faculty facilitator. Clerkship leaders may wish to avail themselves of opportunities such as seminars or workshops to augment their own skills in teaching through problem-based learning.
The clinical problem might be relatively simple or both complex and robust. On the simpler side, consider that the parents of a patient ask a point of information about their infant's immunization schedule -- when is the child next due for immunizations? In order to respond adequately, the student needs first to identify what he or she does not know: What is the recommended pediatric immunization schedule? Further, the student needs to identify relevant information he or she does not know about this particular patient; what is this infant's status with regard to that schedule, which immunizations have already been administered, are the infant's immunizations up-to-date relative to age-recommendations, are there indications or contraindications for administering the remainder of the immunization series? Even such a focused parent question as when the child is next due for immunization may provide a clinical event to motivate student investigation and ultimate learning.
Many of our clinical problems are initially less sharply focused and therefore significantly more complex for new learners. The patient presents with chief complaint and symptomatology; this is the classic clinical problem. Students need to learn to define the problem(s) as clearly as possible, based on the history and then enhanced by the physical examination. Hypotheses about the cause of the problem should follow, with sufficient reasoning about the more likely causes, and inquiries such as laboratory information to document or deny causal hypotheses. Newly acquired data then needs to be fit into the initial hypotheses, which may require substantial modification over the course of problem exploration. Problem-based learning in the clerkship setting can often be enhanced by a small group context, in which the students together identify the case facts, generate causal ideas, and identify what they need to know to move the problem to solution. They then act on those learning issues, using any of several resources (books, journals, other professionals) to shed light on the clinical problem and the operating hypotheses at hand.
The process of problem-based learning occurs with greater or lesser organization and structure each time students enter a clinical encounter; when properly guided in conferences or small group learning sessions, the process should be attractive and exciting to students, because it is largely self-directed and fully motivated by the clinical problem at hand. It demands clinical reasoning skills; it requires the assimilation of information into existing hypotheses; it promotes knowledge sharing and good communication when conducted in the small group setting. The rewards are many- understanding the problem more clearly, discovering cause(s) for signs symptoms, sharpening clinical reasoning skills, reaching diagnostic and then treatment considerations, and of course, expanding knowledge. The reader is referred to Section F: Student Self Directed Learning for fuller discussion of problem-based and self-directed learning.
Self-efficacy - This construct is based in the social learning theory of a major psychologist of our century, Albert Bandura. It involves a distinction between the learning of a task or tasks, such as interviewing skills, procedural skills, giving bad news, Counciling about risk behaviors, and perceiving yourself to be competent and skilled in that trait or task. Mann5 discusses the importance of physicians' self-efficacies and the relationship between self-efficacy and the degree to which the physician will actually engage in or avoid a task. For example, it is likely that you will avoid inquiring about sexual activity and pregnancy precautions in your adolescent patients if you perceive yourself to be rather poorly skilled in doing so; if you perceive yourself to be competent in that area, you will more likely address such issues when it is indicated to do so. The term "learning" is forced to take on a subtle but significant new meaning within the context of self-efficacy. Not only do trainees need exposure and practice with skills such as interviewing, pediatric procedures, giving bad new, but trainees should learn them to a point of competence such that they perceive themselves to be good at the task, comfortable and competent at the task.
Adult Education 7- This term relates to Knowles' theory8 that there is a significant and different readiness for learning in adults, as compared with younger learners. Knowles suggests that the more mature learner has full capacity for self-direction, and usually starts with a problem as central to learning (fitting well with the importance of posing the problem first in problem-based learning). The adult learner is well equipped to use past experience as a resource for future learning, and is well equipped to relate the tasks of learning to his or her needs. An example might suffice to highlight the theoretical position. As a medical student, your newest patient has just been admitted with the likely diagnosis of new-onset diabetes mellitus. You will carefully assess the patient, seek information and direction from textbooks and other resources to upgrade your own knowledge regarding the patient's problem, the diagnostic considerations and treatment considerations. This homework need not be assigned; you want to learn more; you want to present the case clearly and comprehensively amid the fuller group of learners in morning conference; the patient admission is a learning opportunity, timed well for you to gain competence; you see the challenge and are motivated to expand your knowledge and skills toward your ultimate goals.
Greenberg and Jewett7have advanced Knowles' theoretical structure of adult learning further, arguing that we need to sharpen our expertise in problem-solving teaching in order to more fully take advantage of the capacities our students have as adult learners.
Interactive and small group learning - Opportunities for learning are pervasive in the clerkship setting but few such opportunities have the following characteristic: allow the students to explore and discover what they need to know in the problem encounter, provide a facilitator to guide, allow peer support and knowledge sharing, provide active engagement in the issues emerging from the problem, provide time to seek and use learning resources, then provide time to regroup and readdress the problem and resolution options. Small group sessions, such as those of problem-based learning encounters, offer the time, concentration of focus and intimacy of working through the many facets of a patient case along with other new learners and guided by knowledgeable faculty. Riggs9 provides an excellent practical outline for the components of small group learning sessions, such as facilitator training and a problem-based focus to the learning sessions.
There are other forms of small group learning as well. These share some of the features of problem-based sessions, such as a general problem-solving approach to the case, or the need for logical and analytic thought, but all small group learning need not embrace the full structure of problem-based learning. Straight-forward case discussions, held in small interactive groups, allow students to air and explore their questions and their hypotheses about what is going on in a case. Such discussions are often effective learning techniques because they are driven by the learners, and they occur without the sometimes intimidating formality of a structured conference or rounds. Even strategies of small group interaction such as role play might be helpful to illuminating aspects of a case, such as overcoming specific barriers identified in case management or enhancing student skills in effective physician-patient communication or patient education.
In contexts other than small group interactive sessions or the preceptorship model, such as rounds and conferences, many of the topics to which students are exposed are not necessarily ones which the student is able to master or learn more about in the following days. Further, the pace and sophistication of information exchanged is rarely controlled by the student. Nor are patient care decisions rendered and executed at times when they necessarily best meet the student's current learning needs. This can be highly frustrating, especially to students who want very much to learn it all, and sense quite deeply the time pressure and the enormity of the clinical knowledge base. The small group interactive session likely adds a balance to other sources of learning, providing time for depth and breadth of exploration and discovery as well as practice in sharpening clinical reasoning skill.
The Role of Clinical Teachers
Is there a role remaining for teachers as givers-of-information? Is there a role remaining for didactic lectures? Is there a role for the teacher in such self-directed activity? Absolutely so. The teacher is at hand to use cases as springboards for fuller topical discussions, for generalization to broader implications or to parallel, related, or contrasting problems. The teacher needs to reconcile time constraints, tangents, imbalances in participation, and the teacher may need to shape the directions of exploration.
Relatively formal lectures and highly structured conferences, such as a clerkship core lecture set, grand rounds, formal research conferences or pathology reviews, may well play an important role in contributing to the core knowledge base, or even to development of habits of lifelong learning, when they are used to organize an educational framework and reinforce significant principles from practice. Those learning, also have capability to support interactive styles. Even formal lecturers can be adept at requesting audience input and opinion, involving listeners in clinical choices or discussion of options. There is vastly too much information for students to wade through alone; well considered lecture time may help to organize either some topic or some strategies to address the topic. For example, teaching about developmental skills can be overwhelmingly detailed and dry, if ages and skills are simply reviewed. But a briefer session on principles of development accompanied by a subset of example details can be an important strategy of information organization. So, for example, the talk could point out principles such as the directionality evident in the emergence of skills, with pertinent examples, or the time sequence to the development of marker skills for screening, with pertinent examples.
The teacher may help set priorities for learning; the teacher may be the sole resource in a problem-based learning session to expand a particular case or extrapolate from the case at hand to related or contrasting clinical problems, or to epidemiologic or methodologic or health policy issues. Clinical teachers continue to play a vital role in student education, even in an era of medical educational reform with its emphasis on self-directing learning. In fact, as the next section describes, clinical teachers who bring to their work the enthusiasm they have for medicine, emphasize the key points they wish to transmit, and consider the learner's level of knowledge during the teaching interaction, are likely to be celebrated for their teaching talent.
Celebrated clinical teachers
There is strong opinion and even some data on the characteristics which make an individual a particularly effective and celebrated teacher. Inquiries about excellent teacher characteristics generally evoke adjectives and phrases such as: warm, enthusiastic, informative, friendly, really loves the topic, approachable, great role model. Irby3 presents a superb discussion of excellence in clinical teaching, concretizing the areas of skill required as well as the characteristics of teaching excellence in the context of attending rounds. It includes a clear and compelling account of the knowledge of the learners' skills and their usual errors, general expertise in teaching and learning principles. It is difficult to do justice to Irby's3 discussion in summary fashion, but some highlights follow;
A special sort of knowledge emphasized by Irby is that of "content-specific instruction." Having expertise in the content of your field is not enough for effective and talented clinical teaching; the celebrated teacher can organize that information precisely for teaching purposes; Irby refers to the information itself as "scripts: -- scripts of illness, and of particular instances or cases. A good teacher remains aware of key points to get across and how to achieve them (by example, by analogy, by explanation); he or she is aware of the common error patterns or stumbling blocks of learners at particular levels, and ways to help with strategies to cross those hurdles. He or she is aware of the learner's level of knowledge and recognizes the learner as part of a team in which individuals have differing needs and strengths.
Irby3 developed a model from the teaching characteristics of a set of six celebrated attending physicians in Internal Medicine at the University of Washington School of Medicine who were studied during teaching rounds. Among the characteristics flagged by the teachers as essential elements in teaching, were the following: "actively involve learners and ask lots of questions..., capture attention and have fun..., connect the case to broader concepts..., go to bedside..., meet individual needs..., be practical and relevant..., be selective and realistic..., and provide feedback and evaluation..." Irby3. The reader is referred to Irby's discussion of each principle cited above, as well as his broader model of clinical teachers' knowledge. These deserve the attention of any clinical teacher interested in bettering his or her own skills, or guiding other participants in clerkship teaching; each point is well-examined, clearly articulated and illustrated to the reader by example. Although Irby's3 research has extracted teaching characteristics from an inpatient and rounding setting, the characteristics and principles discussed are very likely to be helpful to clinical teachers looking to enhance their skills in the ambulatory setting as well.
Challenges to Optimal Teaching and Learning in the Clerkship
There are significant challenges facing the clerkship director in the effort to maximize teaching effectiveness. At the same time, there are serious academic and emotional challenges for the student.
Learning challenges - Consider first the student issues; each clerkship of the year has new geography, new faces and personalities, differing expectations and requirements, new patient issues, differing practice characteristics and professional nuances and styles. What each clerkship often lacks is time. That is, a relaxed time frame to integrate new knowledge into existing knowledge, and the time and opportunity to practice newly acquired skills and probe newly acquired knowledge sufficiently to perceive oneself as competent and successful. There is as well the initial cohesion and eventual dissolution of the "group" when students come together to learn with one another and from one another.
Students in pediatrics sometimes experience more than the challenge of interesting and expansive new academic material; some of the families and children with whom students work are likely to elicit emotional feelings or even helplessness from the trainee. For some students, such emotions are kept more in check when in other clerkships, but physician-patient communication takes on rather different, complex and intense features when we work closely with families and the diseases of infants and children.
Strategies for meeting such challenges are not easily defined. At a minimum, sufficient and complete orientation to the clerkship's requirements, schedule, professional responsibilities and teaching faculty and residents should be accomplished by the clerkship director. While students may well know their medical school library resources, they do not know particulars about the departmental library or ways to access departmental learning resources. These should be reviewed. Methods to access the clerkship director's attention are worth noting, so that students in either academic or emotional distress have both an invitation and a pathway to seek help.
Teaching challenges - Just as it takes time to integrate new material into existing knowledge fields, it also takes time for the clerkship director to identify where each student is functioning; what particular strengths or deficits the student brings to the academic material of the clerkship. Whether one wants to assist a weak or marginal student with learning aids, more frequent feedback, or structured tutorial meetings, the job of intervention starts, at the very least, with identifying such a student well before the final days of the rotation.
Clerkship directors also struggle with individual differences of a cast of clinical teachers; some may be excellent teachers, some may be poor teachers. Practical problems often prevent us from keeping poor teachers, whether faculty, residents, or allied health staff, away from students entirely in the clinical arena, but one would be ill-advised to insist that poor teachers play central roles in those aspects of clerkship learning over which we do have control. Of course, active faculty development of teaching skills would be an ideal preventive method of minimizing adverse teacher-learner interactions in the clerkship context. Further, the clerkship director is in an excellent position to analyze what might be contributing to a given individual's apparently poor teaching interactions, and how the difficulty might be modified. After all, there are several types of teaching and several teaching contexts within the clerkship. Does the faculty member understand the student's learning goals and objectives? Does the faculty member know what the student's curriculum has included up to the point of their interaction? Is the teacher most comfortable teaching through patient evaluation at the bedside? If so, facilitate learning encounters in the clinical setting, not the classroom or conference room for that teacher. Is this a faculty member who might teach effectively when afforded more frequent interaction with the same group of trainees, instead of episodic teaching encounters with new individuals? The clerkship is likely to be able to maximize effective teaching when a given teacher's instructional strengths are identified and the characteristics or contexts in which that individual's participation is less successful are avoided.
There is a pervasive perspective that reform is due, that optimal
learning includes active participation, discovery, self-direction and practice
with professional role models and guidance in areas of required achievement,
skill and attitude development. To that
end, we should encourage our students to investigate the literature, to take
advantage of computer-assisted instruction, to use the patient as a learning
source for mastering immediate details of evaluation, decision-making and
management. Valued highly as sources of
independent and self-directed learning are the group and highly interactive
settings. Using real or prepared case
scenarios, standardized patients, or video exercises, the small group format
allows learners to identify what they know, and as importantly, what they need
to know. The clerkship setting offers
opportunity for a most important set of life-long skills to be introduced,
practiced and solidified. The course is
best steered for students by enthusiastic facilitators and teachers alert to
many opportunities to teach by example and by discovery.