history: from those who wrote it Excellence in clinical teaching: knowledge transformation and development required David M Irby
CONTEXT Clinical teachers in medicine face the daunting task of mastering the many domains of knowledge needed for practice and teaching. The breadth and complexity of this knowledge continue to increase, as does the difficulty of transforming the knowledge into concepts that are understandable to learners. Properly targeted faculty development has the potential to expedite the knowledge transformation process for clinical teachers. METHODS Based on my own research in clinical teaching and faculty development, as well as the work of others, I describe the unique forms of clinical teacher knowledge, the transformation of that knowledge for teaching purposes and implications for faculty development. RESULTS The following forms of knowledge for clinical teaching in medicine need to be mastered and transformed: (i) knowledge of medicine and patients; (ii) knowledge of context; (iii) knowledge of pedagogy and
learners, and (iv) knowledge integrated into teaching scripts. This knowledge is employed and conveyed through the parallel processes of clinical reasoning and clinical instructional reasoning. Faculty development can facilitate this knowledge transformation process by: (i) examining, deconstructing and practising new teaching scripts; (ii) focusing on foundational concepts; (iii) demonstrating knowledge-in-use, and (iv) creating a supportive organisational climate for clinical teaching. CONCLUSIONS To become an excellent clinical teacher in medicine requires the transformation of multiple forms of knowledge for teaching purposes. These domains of knowledge allow clinical teachers to provide tailored instruction to learners at varying levels in the context of fast-paced and demanding clinical practice. Faculty development can facilitate this knowledge transformation process.
Medical Education 2014; 48: 776–784 doi: 10.1111/medu.12507 Discuss ideas arising from the article at www.mededuc.com ‘discuss’
Office of Medical Education, University of California San Francisco, San Francisco, California, USA
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Correspondence: David M Irby, Office of Medical Education, University of California San Francisco, 521 Parnassus Avenue, San Francisco, California 94143-0410, USA. Tel: +1 415 502 1633; E-mail: [email protected]
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Excellence in clinical teaching Editor’s note: This article is published as part of our celebration of the careers of those individuals who have won the Karolinska Institute Prize for Research in Medical Education.1,2 knowledge’, or PCK.3,4 This knowledge includes the knowledge of content, learners, pedagogy, context and the integration of all of these into teaching scripts.
Dr David M Irby, Professor of Medicine in the Division of General Internal Medicine, research faculty member in the Office of Research and Development in Medical Education at University of California, San Francisco
INTRODUCTION
There is an old joke that periodically makes the rounds in medical circles and it goes something like this: ‘Those who can’t do, teach.’ In other words, those who cannot perform as expert clinicians can teach because it is so much easier. This disparaging comment portrays teaching as something everyone can do, that requires no particular form of expertise and should be left to those who can no longer perform their primary function and higher calling as expert clinicians. Actually, only those who can do well (practise medicine and teach) can become excellent clinical teachers. In fact, excellence in clinical teaching is at the top of the pyramid of complexity and expertise. Knowledge for clinical teaching in medicine involves mastering a wide variety of domains and transforming them for instructional purposes. Years ago at a national meeting, I heard Lee Shulman, a distinguished educator at Stanford University and later President of the Carnegie Foundation for the Advancement of Teaching, speak about the transformation of content knowledge for teaching. Shulman argued that the unique and essential capacity for teaching was the ability to transform one’s content knowledge into something understandable and accessible to learners at their own levels. He was actually addressing the adage that opened this paper by asserting that the taken-for-granted content knowledge of a specialty is insufficient for teaching; an additional and distinctive form of knowledge that only teachers possess is required. Shulman described this special form of teacher knowledge as ‘pedagogical content
Excellence in teaching requires a deep and tightly connected understanding of content in the specialty and a mastery of multiple ways of conveying this knowledge to learners at varying levels of development; thus, teaching is content-specific. Teachers need to understand many different ways of representing their content in order to switch back and forth between the student’s, the discipline’s, the textbook’s and their own conceptions.5 Shulman’s assertion about PCK raises some interesting questions about clinical teaching. What knowledge do physicians need for clinical teaching? In what ways is this knowledge transformed and utilised in clinical and clinical instructional reasoning? How should this research be used to design faculty development programmes? In this article, I reflect on my own research in clinical teaching and faculty development, and connect it to the expanding research of others. This is not intended to be a comprehensive review of the literature, but, rather, an examination of what I have learned about how knowledge is created, transformed and used by clinicians for teaching purposes, and how faculty development can facilitate the acquisition of this knowledge. In order to focus on knowledge transformation, I will not address other important characteristics of clinical teachers, such as their beliefs, identities, motivation and self-efficacy, personal characteristics such as enthusiasm and integrity, or clinical teaching strategies.
KNOWLEDGE TRANSFORMATION FOR CLINICAL TEACHING
Clinical teaching in medicine involves mastering and transforming: (i) knowledge of medicine and patients; (ii) knowledge of context; (iii) knowledge of pedagogy and learners, and (iv) knowledge integrated into teaching scripts (Fig. 1). This knowledge is employed and conveyed through the use of clinical reasoning and clinical instructional reasoning. An illustrative teaching dialogue is shown in Table 1
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D M Irby
Knowledge used for clinical teaching
Knowledge transformed for clinical teaching
Knowledge growth through faculty development
Knowledge of medicine Knowledge of paƟents
Examine, deconstruct and pracƟse new scripts
Knowledge of context
Focus on foundaƟonal concepts
Teaching scripts
Demonstrate knowledge-inuse Create a supporƟve organisaƟonal climate
Knowledge of pedagogy Knowledge of learners
Figure 1 Knowledge for clinical teaching in medicine draws upon multiple forms of knowledge, which are transformed into teaching scripts. These scripts can be further elaborated upon and refined through faculty development activities
to illuminate clinical instructional reasoning and knowledge use in action. Knowledge of medicine and patients In my earliest research, I discovered that excellent clinical teachers have a breadth of knowledge about medicine and teaching, and are able to convey that knowledge in a clear and organised manner.6–8 Facilitating learning in the fast-paced environment of clinical medicine requires the ability to teach in short periods of time and to make the points memorable so learners can retain them. Clear and well-organised presentations are key to representing knowledge in a way that is understandable to learners at varying levels and in response to their requests for information.9 This foundational knowledge of medical science and clinical practice forms the bedrock of clinical teaching. Medical science knowledge is often learned as abstract and decontextualised facts that are separated from clinical experiences. This information is organised into schemata in long-term memory and offers an important coherence for signs and symptoms.10 When students move from the classroom (in which they have learned abstract knowledge) to the clinical world (in which they encounter specific patients), they must reorganise their knowledge. As patients do not present as diseases, but, rather, as signs and symptoms, a new set of mental representations are required. Clinical knowledge includes an understanding of types or
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classifications of patients (e.g. those with diabetes) and specific patients (e.g. Mrs Jones, a 20-year-old woman with uncontrolled diabetes). After a student has seen multiple cases (real, simulated or written), he or she begins to form patterns in long-term memory, thus laying the foundation for more automated reasoning using pattern recognition and illness scripts. Illness scripts represent a type of schemata, which incorporate three components: (i) causal enabling factors; (ii) the disease mechanism or fault, and (iii) the clinical presentation or natural progression of the illness.11–13 This encapsulated knowledge incorporates biomedical knowledge and is used in diagnostic reasoning.14 Both medical science knowledge and illness scripts are required for clinical practice and for clinical teaching. In addition, physicians also retain instances of specific patients in memory associated with particular disease states and courses of treatment. As much of clinical teaching involves demonstrating clinical expertise in action and articulating clinical reasoning in action, clinical teachers draw on all of these forms of medical knowledge. The clinical teacher’s knowledge of the specific patients for whom the team is caring allows the teacher to monitor student and resident interactions with the patient and guide their actions appropriately. Knowledge of contexts Clinical teachers work in a variety of contexts.15 These include out-patient clinics, in-patient services,
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Excellence in clinical teaching
Table 1 A case of knowledge use in action during clinical teaching. An emergency medicine team, which consists of a physician teacher, a medical student and an emergency medicine resident, discuss a newly arrived patient. The teacher is using a one-minute preceptor script
Dialogue
Reasoning process
Knowledge used
Teacher: ‘Tell me about Mrs Jones’
Diagnose learner
Pedagogy
Student: ‘She is a 90-year-old woman who was brought in with rapid
Diagnose patient
Medicine
Teaching script onset of fatigue, chest pain, cough and fever. She was unable to get out
Patients
of bed or come into the ED [emergency department] without assistance’ Teacher: ‘What do you think is causing these symptoms?’
Context Diagnose learner
Pedagogy Teaching script
Student: ‘I think she has pneumonia’
Diagnose learner
Medicine Patients Context Learners
Teacher: ‘What led you to that conclusion?’
Diagnose learner
Pedagogy Learners Teaching script
Student: ‘Her symptoms of productive cough, a temperature of 103, and
Diagnose learner
signs of consolidation on chest exam are consistent with that diagnosis’
Medicine Patients Context Learners
Teacher: ‘I concur.’ [Turns to the resident] ‘What should we do next?’
Diagnose learner
Pedagogy Learners Teaching script
Resident: ‘We should get a chest X-ray, labs including CBC [complete
Diagnose learner
Medicine
blood count] and electrolytes, sputum for gram stain and culture, and
Patients
perhaps an ABG [arterial blood gas] to assess oxygenation. We will need
Context
to start i.v. fluids to rehydrate her, put her on oxygen and administer
Learners
antibiotics. I would like to admit her to the hospital given the severity of her presentation’ Teacher: ‘I concur. Antibiotic therapy will depend upon the infecting
Teach and give feedback
Medicine
organism and whether it is community-acquired or hospital-acquired
Patients
pneumonia. You both did a good job of quickly identifying the problem
Context
and recommending appropriate tests and treatment options. Let’s check
Pedagogy
back as soon as we have the X-ray and lab results’
Learners Teaching script
emergency rooms, operating rooms and conference rooms, among others. In addition, context makes a difference in terms of the types of patients seen, diseases treated and treatment options available, all of which create different opportunities for learning. This knowledge is used in both diagnosing and treating patients, as well as in guiding learners. Clinical teachers not only participate in their clinical communities of practice (e.g. the out-patient
clinic), but often participate in academic and faculty development communities as well (e.g. departments of medicine, teaching scholars programmes). Through these communities of clinical and teaching practice, clinical teachers co-construct knowledge and develop shared understandings about what it means to be a physician and a clinical educator.16,17 These varying contexts influence what, when and how a concept or procedure can and will be taught.
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D M Irby Knowledge of pedagogy and learners In addition to knowledge of medicine, patients and contexts, clinical teachers acquire and master knowledge of general pedagogical strategies. Physicians in training typically develop this pedagogical understanding through the apprenticeship of observation; they learn by observing positive and negative examples of teaching. Commonly used pedagogical strategies include the use of questions, case discussions, observation and feedback, and specific clinical teaching methods such as Aunt Minnie,18 the oneminute preceptor19–24 and SNAPPS [summarise history and findings; narrow the differential; analyse the differential; probe preceptor about uncertainties; plan management; select case-related issues for self-study].25,26 These general teaching strategies are used in clinical teaching and supervision7 to support active learner engagement in clinical work and to create a positive learning climate.8 Over time and with sufficient experience, clinical teachers come to understand what learners know and can do by level. This includes knowledge of students’ typical errors and normal development paths in understanding content.15 These general understandings guide questions of learners to ascertain how closely a specific learner’s knowledge and performance approximate the norm of student performance the clinical teacher has observed in other learners at that stage of development. Such automated schema induction processes utilise questioning and observation strategies to determine how far a specific learner deviates from general expectations, and to offer the appropriate amount of guidance, support and challenge for that level of development.
Others have described this form of knowledge as practical wisdom, which is informal and tacit knowledge used for clinical practice and clinical teaching.29,30 Such knowledge is not always accessible to conscious thought because it is automated and encapsulated, and therefore cannot always be passed on to others. Thus, expert clinicians may not be able to describe how to master a particular skill, whereas expert clinical teachers can do so because they are used to explaining not only how to do the task, but also how to overcome typical errors, all of which are incorporated into their teaching scripts.28
CLINICAL REASONING AND CLINICAL INSTRUCTIONAL REASONING
Knowledge integrated into teaching scripts The quintessential knowledge of clinical teaching is the integration of all of these forms of knowledge into teaching scripts, or what Shulman describes as ‘pedagogical content knowledge’.3,4 All of these forms of knowledge are integrated into case-based teaching scripts.15 Like the script of a play, teaching scripts guide content selection and teaching interactions, allowing the teacher to focus on the learner and the patient without overloading working memory. Teaching scripts typically contain three to five commonly used teaching points, which vary by case, circumstance and teaching method.27 These teaching points are often associated with the teacher’s obser-
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vations of common learner errors in mastering particular clinical topics and tasks. This knowledge of common errors in turn directly affects the teaching points of clinical teachers, who tend to directly address these anticipated errors.28 In addition, teaching scripts change depending on the pedagogical strategies employed. For example, when using the one-minute preceptor model,23 as opposed to the classic case-based clinical teaching model, teachers shift their teaching points away from generic clinical skills (e.g. how to structure an oral case presentation) toward disease-specific instruction (e.g. how to diagnose chronic obstructive pulmonary disease).22 Teaching scripts are also idiosyncratic, making it difficult to determine what commonly shared knowledge will be taught in any given case. Changing these automated teaching scripts to incorporate new teaching strategies requires a great deal of practice before it can be routinized and incorporated into new teaching scripts.
Clinical teachers draw upon these multiple forms of knowledge when engaging in clinical reasoning and clinical instructional reasoning. Physicians encountering patient problems within their domain of expertise make their diagnosis in an automatic, nonanalytic manner. Hypotheses arise from rapid pattern recognition derived from the schemata and illness scripts in long-term memory. Clinicians deviate from this approach when they are outside their domains of expertise or when the problem does not fit a recognisable pattern. In those circumstances, clinicians use a slower, more analytical reasoning process based upon their knowledge of medical science and clinical practice.12,31 This is described as the dual process model by Kahneman: System 1 processing is automated and
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Excellence in clinical teaching instantaneous pattern recognition, and System 2 processing is conscious, slow, deliberate and analytical.32 A combination of both reasoning processes is routinely used in practice. In the midst of clinical teaching, the initial reasoning process is clinical and involves diagnosing the patient or determining treatment options, depending on what is needed for patient care. This is part of the interactive thinking process that occurs in real-time case-based teaching, which precedes and often parallels the diagnosis of the learner. The combination of these two reasoning processes (clinical and instructional) leads the clinical teacher to select an appropriate diagnosis for the patient from an illness script, and an instructional point from a teaching script. In addition to this form of thinking in action, excellent clinical teachers also engage in anticipatory planning and preparation before clinical teaching, and invest time and energy in evaluation and reflection afterward.27 Reasoning about clinical teaching is both improvised and scripted; it parallels but is distinct from the clinical reasoning process. Initial diagnosis is similar, although the focus is different (patient versus learner). Clinical instructional reasoning connects the teacher’s knowledge and thoughts (planning, diagnosis of patient and learner, interactive teaching and reflection) with the dynamic requirements of the clinical setting in order to provide targeted instruction to the needs of his or her learners.27 This whole process is monitored by metacognition, which mirrors anticipatory planning, monitoring in real time, and reflecting afterward.33
The diverse forms of knowledge are changed into teaching scripts through repeated teaching, planning, reflection and faculty development. Clinical teachers reason through dilemmas in learning, investigate problems and analyse student learning in order to create appropriate instruction for a typically diverse group of learners. In faculty development, this knowledge and reasoning process can be described, modelled and practised, thereby helping clinical teachers to prepare in advance and to focus on diagnosing their learners as well as their patients. Based on my own experience and research in faculty development, I describe four implications of this knowledge transformation process for faculty development: (i) examine, deconstruct and practise new scripts; (ii) focus on foundational concepts; (iii) demonstrate knowledge-in-use, and (iv) create a supportive organisational climate for clinical teaching (Fig. 1). Examine, deconstruct and practise new scripts Because all clinical teachers, even those who are novices, have had years of teaching experience during their training, new teaching scripts are built on prior scripts. Prior knowledge and prior scripts can help or hinder learning of new teaching practices.38 This has two implications: firstly, clinical teachers need to examine their own teaching scripts, and secondly, they need to practise new pedagogies and content enough to allow these new formulations to compete with, and potentially displace, older scripts.
KNOWLEDGE GROWTH THROUGH FACULTY DEVELOPMENT
For example, many clinical teachers who participate in workshops on the one-minute preceptor23 think that they use the model in their teaching. However, when they are required to practise and be observed using the model, they discover that their existing teaching scripts are at variance with the new model. Hence, the first step toward engaging clinical teachers in learning a new pedagogy is to trigger a more accurate self-perception of their existing teaching scripts. The literature on physician self-assessment suggests that this is no easy task.39–41 On the basis of their self-discovery and sometimes surprise, they can begin to see how the new model differs from their current model. Then they can begin the process of engaging with the new model and figuring out how to incorporate it into their teaching. This process can be prompted in faculty development workshops.
Knowledge transformation for clinical teaching is a complex and ongoing process for clinical teachers.
The longer clinicians teach a particular topic or skill, the more routine and automated the inter-
One of the important findings in this area of research is that excellent clinical teachers engage in a great deal of planning beforehand, and evaluation and reflection afterward.27,34 Excellent clinical teachers approach their work with adaptability and inquiry, thus stretching their knowledge in routine situations, resulting in innovation and improvement.35,36 Less exemplary clinical teachers engage in less reflection and become experienced nonexperts.37
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D M Irby change becomes. Multiple practice opportunities must be included in faculty development sessions in order to create an initial script that can be refined and revised later with further practice. This works best using the deliberate practice model and having a coach watch the new skills being practised.42–44 Thus, demonstrating and discussing new pedagogies without practice will typically not change behaviour. Sometimes modifying existing scripts is so difficult that it is necessary to break the whole task into component parts and participate in part practice. Either way, repeated practice with feedback is necessary.45 Focus on foundational concepts One of the most difficult to master aspects of teaching concerns deciding what content to leave out of a presentation. Being able to reduce the myriad of details to essential and highly simplified concepts is part of the process of learning to teach effectively. Every discipline, specialty and practice has organising principles and foundational concepts, which, if understood by learners, offer them access to the field and comprehension of otherwise mysterious practices. For example, emergency medicine physicians must make decisions on whether to admit patients to hospital or treat and send them home. This foundational decision creates the context for decision making, reduces complexity and focuses action. Learners benefit from understanding these frameworks for action. Clinical teachers report that the longer they teach, the more they go back to basic concepts in their instruction.46 Faculty development can promote discussion of these fundamental conceptual frameworks and help dispel the common belief that teachers must teach all the facts (rather than core concepts). With increasing emphasis on interprofessional education and team-based care, faculty members need to be prepared to teach in these new settings, in which mental models, professional practices and teaching scripts are not held in common. There are significant advantages to incorporating participants from differing specialties and professions in faculty development because the diversity enriches understanding, challenges assumptions and expands perspectives. However, there is a cost in terms of the time required to achieve shared understanding and tolerance for diverse points of view. One strategy is to focus initially on shared roles, tasks and understandings in areas such as team communication, systems change, leadership and feedback. Faculty development across professions will continue to evolve as new foundational
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knowledge is created through interprofessional practice. Demonstrate knowledge-in-use Faculty developers can model best teaching practices in faculty development workshops and demonstrate knowledge use in action. New clinical teachers in particular benefit from observing good teaching practices, especially when demonstrated in the context of their clinical workplace. This might involve observing a master clinical teacher demonstrate a teaching practice, such as giving feedback or teaching about clinical reasoning, in the context of an out-patient clinic or small-group conference. Seeing a demonstration of the complete task or skill helps the observer to visualise the outcomes desired and the ways in which the skill might be used in teaching practice. Observing and practising the whole task can lead to the insights needed to develop and integrate component skills and can facilitate the application of the task to new settings.47 When teaching new general pedagogical strategies in workshops, such as that of facilitating a discussion, the new techniques should be embedded within the content knowledge to be taught in order to maximise transfer and use. This is why tutor guides that include both content information and instructional guidelines are most helpful. In essence, these guides scaffold the whole process and make pedagogical content knowledge partially visible. In contexts in which skills are to be practised, such as in giving feedback, the practice cases should portray common cases seen in the specialty, and should progress from simple to complex cases. Part of learning best practices in education is acquiring a new language about learning. This can involve understanding learning theories (e.g. behavioural, cognitive, social), new concepts (e.g. PCK, cognitive apprenticeship), and general pedagogical skills (e.g. the one-minute preceptor). Having a language in which to talk about instructional challenges and dilemmas facilitates the creation of new insights, new strategies and new scripts, and a new community of teachers. Create a supportive organisational climate Knowledge for teaching is co-constructed within communities of practice. As such, faculty development programmes should incorporate collaborative
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Excellence in clinical teaching learning and strengthen connections among participants, thereby creating a transitory community or teaching commons.48 However, teachers also work within communities of practice in their classrooms and clinical settings. Most faculty development programmes focus on the transitory community created in a workshop or longitudinal fellowship programme, and ignore the workplace learning communities of teaching practice. New strategies need to be formulated to improve teaching in the workplace.49 Creating a culture that is committed to supporting the professional development of clinical teachers requires institutional leadership and support, faculty development, resources and planning.49,50 The process can start within a micro-system of one clinic or one course, or at the departmental or institutional level. Ideally, institutions value clinical teachers, reward them appropriately, and offer forums within which clinical teachers can come together to explore issues related to teaching and learning, thus creating a vibrant learning community. Such learning organisations and their associated faculty development programmes are supportive of clinical teachers and protective against burnout because they continuously rekindle the excitement and joy of teaching, and provide a network of equally enthusiastic teachers.
CONCLUSIONS
Knowledge transformation for clinical teaching is a multidimensional and ongoing process. Excellence in clinical teaching requires knowledge of medicine, patients and context, plus educational knowledge of pedagogy and learners, and case-based teaching scripts. These forms of knowledge are used in clinical instructional reasoning to plan, interactively teach and reflect on instruction. This research can be used to facilitate knowledge transformation through faculty development by: (i) examining, deconstructing and practising new scripts; (ii) focusing on foundational concepts; (iii) demonstrating knowledge-in-use, and (iv) creating a supportive organisational climate for clinical teaching. Over the past four decades, I have been privileged to contribute to and benefit from this research into clinical teaching and faculty development, and I eagerly look forward to a future filled with new insights.
Acknowledgements: I wish to acknowledge the seminal contributions of Lee Shulman, Professor Emeritus at
Stanford University, which stimulated and guided my research, Lauren Maggio (Stanford University) for her contributions to the literature search for this article, and Drs Eva Aagaard (University of Colorado), Judith Bowen (Oregon Health and Sciences University), Gurpreet Dahliwal (University of California San Francisco), Patricia O’Sullivan (University of California San Francisco), Deborah Simpson (Aurora Health Care) and John Q Young (Hofstra University) for their review of the manuscript. Funding: none. Conflicts of interest: none. Ethical approval: not applicable.
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Received 21 December 2013; editorial comments to author 20 January 2014, 18 February 2014; accepted for publication 14 April 2014
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CONTEXT Clinical teachers in medicine face the daunting task of mastering the many domains of knowledge needed for practice and teaching. The breadth and complexity of this knowledge continue to increase, as does the difficulty of transforming the knowledge into concepts that are understandable to learners. Properly targeted faculty development has the potential to expedite the knowledge transformation process for clinical teachers. METHODS Based on my own research in clinical teaching and faculty development, as well as the work of others, I describe the unique forms of clinical teacher knowledge, the transformation of that knowledge for teaching purposes and implications for faculty development. RESULTS The following forms of knowledge for clinical teaching in medicine need to be mastered and transformed: (i) knowledge of medicine and patients; (ii) knowledge of context; (iii) knowledge of pedagogy and
learners, and (iv) knowledge integrated into teaching scripts. This knowledge is employed and conveyed through the parallel processes of clinical reasoning and clinical instructional reasoning. Faculty development can facilitate this knowledge transformation process by: (i) examining, deconstructing and practising new teaching scripts; (ii) focusing on foundational concepts; (iii) demonstrating knowledge-in-use, and (iv) creating a supportive organisational climate for clinical teaching. CONCLUSIONS To become an excellent clinical teacher in medicine requires the transformation of multiple forms of knowledge for teaching purposes. These domains of knowledge allow clinical teachers to provide tailored instruction to learners at varying levels in the context of fast-paced and demanding clinical practice. Faculty development can facilitate this knowledge transformation process.
Medical Education 2014; 48: 776–784 doi: 10.1111/medu.12507 Discuss ideas arising from the article at www.mededuc.com ‘discuss’
Office of Medical Education, University of California San Francisco, San Francisco, California, USA
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Correspondence: David M Irby, Office of Medical Education, University of California San Francisco, 521 Parnassus Avenue, San Francisco, California 94143-0410, USA. Tel: +1 415 502 1633; E-mail: [email protected]
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Excellence in clinical teaching Editor’s note: This article is published as part of our celebration of the careers of those individuals who have won the Karolinska Institute Prize for Research in Medical Education.1,2 knowledge’, or PCK.3,4 This knowledge includes the knowledge of content, learners, pedagogy, context and the integration of all of these into teaching scripts.
Dr David M Irby, Professor of Medicine in the Division of General Internal Medicine, research faculty member in the Office of Research and Development in Medical Education at University of California, San Francisco
INTRODUCTION
There is an old joke that periodically makes the rounds in medical circles and it goes something like this: ‘Those who can’t do, teach.’ In other words, those who cannot perform as expert clinicians can teach because it is so much easier. This disparaging comment portrays teaching as something everyone can do, that requires no particular form of expertise and should be left to those who can no longer perform their primary function and higher calling as expert clinicians. Actually, only those who can do well (practise medicine and teach) can become excellent clinical teachers. In fact, excellence in clinical teaching is at the top of the pyramid of complexity and expertise. Knowledge for clinical teaching in medicine involves mastering a wide variety of domains and transforming them for instructional purposes. Years ago at a national meeting, I heard Lee Shulman, a distinguished educator at Stanford University and later President of the Carnegie Foundation for the Advancement of Teaching, speak about the transformation of content knowledge for teaching. Shulman argued that the unique and essential capacity for teaching was the ability to transform one’s content knowledge into something understandable and accessible to learners at their own levels. He was actually addressing the adage that opened this paper by asserting that the taken-for-granted content knowledge of a specialty is insufficient for teaching; an additional and distinctive form of knowledge that only teachers possess is required. Shulman described this special form of teacher knowledge as ‘pedagogical content
Excellence in teaching requires a deep and tightly connected understanding of content in the specialty and a mastery of multiple ways of conveying this knowledge to learners at varying levels of development; thus, teaching is content-specific. Teachers need to understand many different ways of representing their content in order to switch back and forth between the student’s, the discipline’s, the textbook’s and their own conceptions.5 Shulman’s assertion about PCK raises some interesting questions about clinical teaching. What knowledge do physicians need for clinical teaching? In what ways is this knowledge transformed and utilised in clinical and clinical instructional reasoning? How should this research be used to design faculty development programmes? In this article, I reflect on my own research in clinical teaching and faculty development, and connect it to the expanding research of others. This is not intended to be a comprehensive review of the literature, but, rather, an examination of what I have learned about how knowledge is created, transformed and used by clinicians for teaching purposes, and how faculty development can facilitate the acquisition of this knowledge. In order to focus on knowledge transformation, I will not address other important characteristics of clinical teachers, such as their beliefs, identities, motivation and self-efficacy, personal characteristics such as enthusiasm and integrity, or clinical teaching strategies.
KNOWLEDGE TRANSFORMATION FOR CLINICAL TEACHING
Clinical teaching in medicine involves mastering and transforming: (i) knowledge of medicine and patients; (ii) knowledge of context; (iii) knowledge of pedagogy and learners, and (iv) knowledge integrated into teaching scripts (Fig. 1). This knowledge is employed and conveyed through the use of clinical reasoning and clinical instructional reasoning. An illustrative teaching dialogue is shown in Table 1
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D M Irby
Knowledge used for clinical teaching
Knowledge transformed for clinical teaching
Knowledge growth through faculty development
Knowledge of medicine Knowledge of paƟents
Examine, deconstruct and pracƟse new scripts
Knowledge of context
Focus on foundaƟonal concepts
Teaching scripts
Demonstrate knowledge-inuse Create a supporƟve organisaƟonal climate
Knowledge of pedagogy Knowledge of learners
Figure 1 Knowledge for clinical teaching in medicine draws upon multiple forms of knowledge, which are transformed into teaching scripts. These scripts can be further elaborated upon and refined through faculty development activities
to illuminate clinical instructional reasoning and knowledge use in action. Knowledge of medicine and patients In my earliest research, I discovered that excellent clinical teachers have a breadth of knowledge about medicine and teaching, and are able to convey that knowledge in a clear and organised manner.6–8 Facilitating learning in the fast-paced environment of clinical medicine requires the ability to teach in short periods of time and to make the points memorable so learners can retain them. Clear and well-organised presentations are key to representing knowledge in a way that is understandable to learners at varying levels and in response to their requests for information.9 This foundational knowledge of medical science and clinical practice forms the bedrock of clinical teaching. Medical science knowledge is often learned as abstract and decontextualised facts that are separated from clinical experiences. This information is organised into schemata in long-term memory and offers an important coherence for signs and symptoms.10 When students move from the classroom (in which they have learned abstract knowledge) to the clinical world (in which they encounter specific patients), they must reorganise their knowledge. As patients do not present as diseases, but, rather, as signs and symptoms, a new set of mental representations are required. Clinical knowledge includes an understanding of types or
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classifications of patients (e.g. those with diabetes) and specific patients (e.g. Mrs Jones, a 20-year-old woman with uncontrolled diabetes). After a student has seen multiple cases (real, simulated or written), he or she begins to form patterns in long-term memory, thus laying the foundation for more automated reasoning using pattern recognition and illness scripts. Illness scripts represent a type of schemata, which incorporate three components: (i) causal enabling factors; (ii) the disease mechanism or fault, and (iii) the clinical presentation or natural progression of the illness.11–13 This encapsulated knowledge incorporates biomedical knowledge and is used in diagnostic reasoning.14 Both medical science knowledge and illness scripts are required for clinical practice and for clinical teaching. In addition, physicians also retain instances of specific patients in memory associated with particular disease states and courses of treatment. As much of clinical teaching involves demonstrating clinical expertise in action and articulating clinical reasoning in action, clinical teachers draw on all of these forms of medical knowledge. The clinical teacher’s knowledge of the specific patients for whom the team is caring allows the teacher to monitor student and resident interactions with the patient and guide their actions appropriately. Knowledge of contexts Clinical teachers work in a variety of contexts.15 These include out-patient clinics, in-patient services,
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Excellence in clinical teaching
Table 1 A case of knowledge use in action during clinical teaching. An emergency medicine team, which consists of a physician teacher, a medical student and an emergency medicine resident, discuss a newly arrived patient. The teacher is using a one-minute preceptor script
Dialogue
Reasoning process
Knowledge used
Teacher: ‘Tell me about Mrs Jones’
Diagnose learner
Pedagogy
Student: ‘She is a 90-year-old woman who was brought in with rapid
Diagnose patient
Medicine
Teaching script onset of fatigue, chest pain, cough and fever. She was unable to get out
Patients
of bed or come into the ED [emergency department] without assistance’ Teacher: ‘What do you think is causing these symptoms?’
Context Diagnose learner
Pedagogy Teaching script
Student: ‘I think she has pneumonia’
Diagnose learner
Medicine Patients Context Learners
Teacher: ‘What led you to that conclusion?’
Diagnose learner
Pedagogy Learners Teaching script
Student: ‘Her symptoms of productive cough, a temperature of 103, and
Diagnose learner
signs of consolidation on chest exam are consistent with that diagnosis’
Medicine Patients Context Learners
Teacher: ‘I concur.’ [Turns to the resident] ‘What should we do next?’
Diagnose learner
Pedagogy Learners Teaching script
Resident: ‘We should get a chest X-ray, labs including CBC [complete
Diagnose learner
Medicine
blood count] and electrolytes, sputum for gram stain and culture, and
Patients
perhaps an ABG [arterial blood gas] to assess oxygenation. We will need
Context
to start i.v. fluids to rehydrate her, put her on oxygen and administer
Learners
antibiotics. I would like to admit her to the hospital given the severity of her presentation’ Teacher: ‘I concur. Antibiotic therapy will depend upon the infecting
Teach and give feedback
Medicine
organism and whether it is community-acquired or hospital-acquired
Patients
pneumonia. You both did a good job of quickly identifying the problem
Context
and recommending appropriate tests and treatment options. Let’s check
Pedagogy
back as soon as we have the X-ray and lab results’
Learners Teaching script
emergency rooms, operating rooms and conference rooms, among others. In addition, context makes a difference in terms of the types of patients seen, diseases treated and treatment options available, all of which create different opportunities for learning. This knowledge is used in both diagnosing and treating patients, as well as in guiding learners. Clinical teachers not only participate in their clinical communities of practice (e.g. the out-patient
clinic), but often participate in academic and faculty development communities as well (e.g. departments of medicine, teaching scholars programmes). Through these communities of clinical and teaching practice, clinical teachers co-construct knowledge and develop shared understandings about what it means to be a physician and a clinical educator.16,17 These varying contexts influence what, when and how a concept or procedure can and will be taught.
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D M Irby Knowledge of pedagogy and learners In addition to knowledge of medicine, patients and contexts, clinical teachers acquire and master knowledge of general pedagogical strategies. Physicians in training typically develop this pedagogical understanding through the apprenticeship of observation; they learn by observing positive and negative examples of teaching. Commonly used pedagogical strategies include the use of questions, case discussions, observation and feedback, and specific clinical teaching methods such as Aunt Minnie,18 the oneminute preceptor19–24 and SNAPPS [summarise history and findings; narrow the differential; analyse the differential; probe preceptor about uncertainties; plan management; select case-related issues for self-study].25,26 These general teaching strategies are used in clinical teaching and supervision7 to support active learner engagement in clinical work and to create a positive learning climate.8 Over time and with sufficient experience, clinical teachers come to understand what learners know and can do by level. This includes knowledge of students’ typical errors and normal development paths in understanding content.15 These general understandings guide questions of learners to ascertain how closely a specific learner’s knowledge and performance approximate the norm of student performance the clinical teacher has observed in other learners at that stage of development. Such automated schema induction processes utilise questioning and observation strategies to determine how far a specific learner deviates from general expectations, and to offer the appropriate amount of guidance, support and challenge for that level of development.
Others have described this form of knowledge as practical wisdom, which is informal and tacit knowledge used for clinical practice and clinical teaching.29,30 Such knowledge is not always accessible to conscious thought because it is automated and encapsulated, and therefore cannot always be passed on to others. Thus, expert clinicians may not be able to describe how to master a particular skill, whereas expert clinical teachers can do so because they are used to explaining not only how to do the task, but also how to overcome typical errors, all of which are incorporated into their teaching scripts.28
CLINICAL REASONING AND CLINICAL INSTRUCTIONAL REASONING
Knowledge integrated into teaching scripts The quintessential knowledge of clinical teaching is the integration of all of these forms of knowledge into teaching scripts, or what Shulman describes as ‘pedagogical content knowledge’.3,4 All of these forms of knowledge are integrated into case-based teaching scripts.15 Like the script of a play, teaching scripts guide content selection and teaching interactions, allowing the teacher to focus on the learner and the patient without overloading working memory. Teaching scripts typically contain three to five commonly used teaching points, which vary by case, circumstance and teaching method.27 These teaching points are often associated with the teacher’s obser-
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vations of common learner errors in mastering particular clinical topics and tasks. This knowledge of common errors in turn directly affects the teaching points of clinical teachers, who tend to directly address these anticipated errors.28 In addition, teaching scripts change depending on the pedagogical strategies employed. For example, when using the one-minute preceptor model,23 as opposed to the classic case-based clinical teaching model, teachers shift their teaching points away from generic clinical skills (e.g. how to structure an oral case presentation) toward disease-specific instruction (e.g. how to diagnose chronic obstructive pulmonary disease).22 Teaching scripts are also idiosyncratic, making it difficult to determine what commonly shared knowledge will be taught in any given case. Changing these automated teaching scripts to incorporate new teaching strategies requires a great deal of practice before it can be routinized and incorporated into new teaching scripts.
Clinical teachers draw upon these multiple forms of knowledge when engaging in clinical reasoning and clinical instructional reasoning. Physicians encountering patient problems within their domain of expertise make their diagnosis in an automatic, nonanalytic manner. Hypotheses arise from rapid pattern recognition derived from the schemata and illness scripts in long-term memory. Clinicians deviate from this approach when they are outside their domains of expertise or when the problem does not fit a recognisable pattern. In those circumstances, clinicians use a slower, more analytical reasoning process based upon their knowledge of medical science and clinical practice.12,31 This is described as the dual process model by Kahneman: System 1 processing is automated and
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Excellence in clinical teaching instantaneous pattern recognition, and System 2 processing is conscious, slow, deliberate and analytical.32 A combination of both reasoning processes is routinely used in practice. In the midst of clinical teaching, the initial reasoning process is clinical and involves diagnosing the patient or determining treatment options, depending on what is needed for patient care. This is part of the interactive thinking process that occurs in real-time case-based teaching, which precedes and often parallels the diagnosis of the learner. The combination of these two reasoning processes (clinical and instructional) leads the clinical teacher to select an appropriate diagnosis for the patient from an illness script, and an instructional point from a teaching script. In addition to this form of thinking in action, excellent clinical teachers also engage in anticipatory planning and preparation before clinical teaching, and invest time and energy in evaluation and reflection afterward.27 Reasoning about clinical teaching is both improvised and scripted; it parallels but is distinct from the clinical reasoning process. Initial diagnosis is similar, although the focus is different (patient versus learner). Clinical instructional reasoning connects the teacher’s knowledge and thoughts (planning, diagnosis of patient and learner, interactive teaching and reflection) with the dynamic requirements of the clinical setting in order to provide targeted instruction to the needs of his or her learners.27 This whole process is monitored by metacognition, which mirrors anticipatory planning, monitoring in real time, and reflecting afterward.33
The diverse forms of knowledge are changed into teaching scripts through repeated teaching, planning, reflection and faculty development. Clinical teachers reason through dilemmas in learning, investigate problems and analyse student learning in order to create appropriate instruction for a typically diverse group of learners. In faculty development, this knowledge and reasoning process can be described, modelled and practised, thereby helping clinical teachers to prepare in advance and to focus on diagnosing their learners as well as their patients. Based on my own experience and research in faculty development, I describe four implications of this knowledge transformation process for faculty development: (i) examine, deconstruct and practise new scripts; (ii) focus on foundational concepts; (iii) demonstrate knowledge-in-use, and (iv) create a supportive organisational climate for clinical teaching (Fig. 1). Examine, deconstruct and practise new scripts Because all clinical teachers, even those who are novices, have had years of teaching experience during their training, new teaching scripts are built on prior scripts. Prior knowledge and prior scripts can help or hinder learning of new teaching practices.38 This has two implications: firstly, clinical teachers need to examine their own teaching scripts, and secondly, they need to practise new pedagogies and content enough to allow these new formulations to compete with, and potentially displace, older scripts.
KNOWLEDGE GROWTH THROUGH FACULTY DEVELOPMENT
For example, many clinical teachers who participate in workshops on the one-minute preceptor23 think that they use the model in their teaching. However, when they are required to practise and be observed using the model, they discover that their existing teaching scripts are at variance with the new model. Hence, the first step toward engaging clinical teachers in learning a new pedagogy is to trigger a more accurate self-perception of their existing teaching scripts. The literature on physician self-assessment suggests that this is no easy task.39–41 On the basis of their self-discovery and sometimes surprise, they can begin to see how the new model differs from their current model. Then they can begin the process of engaging with the new model and figuring out how to incorporate it into their teaching. This process can be prompted in faculty development workshops.
Knowledge transformation for clinical teaching is a complex and ongoing process for clinical teachers.
The longer clinicians teach a particular topic or skill, the more routine and automated the inter-
One of the important findings in this area of research is that excellent clinical teachers engage in a great deal of planning beforehand, and evaluation and reflection afterward.27,34 Excellent clinical teachers approach their work with adaptability and inquiry, thus stretching their knowledge in routine situations, resulting in innovation and improvement.35,36 Less exemplary clinical teachers engage in less reflection and become experienced nonexperts.37
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D M Irby change becomes. Multiple practice opportunities must be included in faculty development sessions in order to create an initial script that can be refined and revised later with further practice. This works best using the deliberate practice model and having a coach watch the new skills being practised.42–44 Thus, demonstrating and discussing new pedagogies without practice will typically not change behaviour. Sometimes modifying existing scripts is so difficult that it is necessary to break the whole task into component parts and participate in part practice. Either way, repeated practice with feedback is necessary.45 Focus on foundational concepts One of the most difficult to master aspects of teaching concerns deciding what content to leave out of a presentation. Being able to reduce the myriad of details to essential and highly simplified concepts is part of the process of learning to teach effectively. Every discipline, specialty and practice has organising principles and foundational concepts, which, if understood by learners, offer them access to the field and comprehension of otherwise mysterious practices. For example, emergency medicine physicians must make decisions on whether to admit patients to hospital or treat and send them home. This foundational decision creates the context for decision making, reduces complexity and focuses action. Learners benefit from understanding these frameworks for action. Clinical teachers report that the longer they teach, the more they go back to basic concepts in their instruction.46 Faculty development can promote discussion of these fundamental conceptual frameworks and help dispel the common belief that teachers must teach all the facts (rather than core concepts). With increasing emphasis on interprofessional education and team-based care, faculty members need to be prepared to teach in these new settings, in which mental models, professional practices and teaching scripts are not held in common. There are significant advantages to incorporating participants from differing specialties and professions in faculty development because the diversity enriches understanding, challenges assumptions and expands perspectives. However, there is a cost in terms of the time required to achieve shared understanding and tolerance for diverse points of view. One strategy is to focus initially on shared roles, tasks and understandings in areas such as team communication, systems change, leadership and feedback. Faculty development across professions will continue to evolve as new foundational
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knowledge is created through interprofessional practice. Demonstrate knowledge-in-use Faculty developers can model best teaching practices in faculty development workshops and demonstrate knowledge use in action. New clinical teachers in particular benefit from observing good teaching practices, especially when demonstrated in the context of their clinical workplace. This might involve observing a master clinical teacher demonstrate a teaching practice, such as giving feedback or teaching about clinical reasoning, in the context of an out-patient clinic or small-group conference. Seeing a demonstration of the complete task or skill helps the observer to visualise the outcomes desired and the ways in which the skill might be used in teaching practice. Observing and practising the whole task can lead to the insights needed to develop and integrate component skills and can facilitate the application of the task to new settings.47 When teaching new general pedagogical strategies in workshops, such as that of facilitating a discussion, the new techniques should be embedded within the content knowledge to be taught in order to maximise transfer and use. This is why tutor guides that include both content information and instructional guidelines are most helpful. In essence, these guides scaffold the whole process and make pedagogical content knowledge partially visible. In contexts in which skills are to be practised, such as in giving feedback, the practice cases should portray common cases seen in the specialty, and should progress from simple to complex cases. Part of learning best practices in education is acquiring a new language about learning. This can involve understanding learning theories (e.g. behavioural, cognitive, social), new concepts (e.g. PCK, cognitive apprenticeship), and general pedagogical skills (e.g. the one-minute preceptor). Having a language in which to talk about instructional challenges and dilemmas facilitates the creation of new insights, new strategies and new scripts, and a new community of teachers. Create a supportive organisational climate Knowledge for teaching is co-constructed within communities of practice. As such, faculty development programmes should incorporate collaborative
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Excellence in clinical teaching learning and strengthen connections among participants, thereby creating a transitory community or teaching commons.48 However, teachers also work within communities of practice in their classrooms and clinical settings. Most faculty development programmes focus on the transitory community created in a workshop or longitudinal fellowship programme, and ignore the workplace learning communities of teaching practice. New strategies need to be formulated to improve teaching in the workplace.49 Creating a culture that is committed to supporting the professional development of clinical teachers requires institutional leadership and support, faculty development, resources and planning.49,50 The process can start within a micro-system of one clinic or one course, or at the departmental or institutional level. Ideally, institutions value clinical teachers, reward them appropriately, and offer forums within which clinical teachers can come together to explore issues related to teaching and learning, thus creating a vibrant learning community. Such learning organisations and their associated faculty development programmes are supportive of clinical teachers and protective against burnout because they continuously rekindle the excitement and joy of teaching, and provide a network of equally enthusiastic teachers.
CONCLUSIONS
Knowledge transformation for clinical teaching is a multidimensional and ongoing process. Excellence in clinical teaching requires knowledge of medicine, patients and context, plus educational knowledge of pedagogy and learners, and case-based teaching scripts. These forms of knowledge are used in clinical instructional reasoning to plan, interactively teach and reflect on instruction. This research can be used to facilitate knowledge transformation through faculty development by: (i) examining, deconstructing and practising new scripts; (ii) focusing on foundational concepts; (iii) demonstrating knowledge-in-use, and (iv) creating a supportive organisational climate for clinical teaching. Over the past four decades, I have been privileged to contribute to and benefit from this research into clinical teaching and faculty development, and I eagerly look forward to a future filled with new insights.
Acknowledgements: I wish to acknowledge the seminal contributions of Lee Shulman, Professor Emeritus at
Stanford University, which stimulated and guided my research, Lauren Maggio (Stanford University) for her contributions to the literature search for this article, and Drs Eva Aagaard (University of Colorado), Judith Bowen (Oregon Health and Sciences University), Gurpreet Dahliwal (University of California San Francisco), Patricia O’Sullivan (University of California San Francisco), Deborah Simpson (Aurora Health Care) and John Q Young (Hofstra University) for their review of the manuscript. Funding: none. Conflicts of interest: none. Ethical approval: not applicable.
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Received 21 December 2013; editorial comments to author 20 January 2014, 18 February 2014; accepted for publication 14 April 2014
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