Modicrrl Editcution, 1979, 13, 86-90
The art and science of clinical teaching A N N E T T E M. Y O N K E Center f o r Educational Dcvdopment. University of Illinois Medical Center, C l i i c ~ g oIllinois ,
using the same methods of several generations ago. However, in this age of student influence in the A review of the literature on clinical teaching indiacademic world, students’ criticism of teaching cslls cates that medical schools emphasize didactic for examination of practices long taken for granted. teaching of facts. Interpersonal skills, problem The purpose of this review is to identify the skills solving skills and cultivation of attitudes are for effective clinical teaching; to describe programmes neglected. However, the literature also describes where innovative clinical teaching occurs; to indicate the skills of ‘good’ clinical teachers, and enumerates some of the problems in clinical teaching; and to them. Programmes attempting to develop students’ recommend some areas for further practice and interpersonal skills and problem solving skills are research in clinical teaching. reported. Finally, areas for further practice and study The literature on clinical teaching in the last in clinical teaching are recommended. decade emphasizes factual information and neglect of emphasis o n the patient as deficiencies in clinical Keywords: TEACHING/*methOdS; ’CLINICAL teaching. Factual information has traditionally been assessed in determining the quality of student learnSKILLS;*EDUCATION, MEDICAL, UNDERGRADUATE; ing (Bashook, 1976). Examinations focus on the PROBLEMSOLVING; EVALUATION STUDIES;DIAGmaterial students learn rather than on their diagnostic NOSIS; SELF PERCEPTION and interpersonal skills. As a result students do not learn about psychological or sociological aspects of Introduction patient care (Goroll, 1974). Clinical teachers are seen to be preoccupied with didactic teaching. Clinical teachers in medical schools find it difficult Ward rounds are didactic experiences conducted to identify the specific steps and skills they use in without patients, often occurring not at the bedside teaching. They also admit giving limited thought but in a meeting room where the patient is not seen to the process they use to arrive at a diagnosis of but merely discussed. When bedside rounds do occur, disease. When questioned about their skills, they students are passive onlookers. In clinical condescribe their teaching and the process of diagnosis ferences teachers lecture to only a handful of students as ‘art’. As successful teachers they practise their with no question and answer period. Seminars differ teaching craft and perform their problem-solving from such sessions in that students, not the instrucintuitively, Their students learn through the same tor, lecture (Reichsman et a/.,1964). Since clinical mode of intuition and inspiration-not altogether teachers are still operating under the misguided an undesirable method of learning. view that students should see as many interesting But ‘born teachers’ number only a few among the cases as possible, little attempt has been made to ranks of clinical teachers in medical shook. Those teach and assess clinical interviewing and physical having less artistry perform their teaching tasks examination skills other than in psychiatry (Newble, Correspondence: Dr Annette M. Yonke, Center f o r 1973). Educational Development, University of Illinois Medical The emphasis on factual information is further Center, 808 South Wood Street, Room 973, Chicago, Illinois, 60612, U . S . A . confirmed by research findings that indicate clinical teachers create a halo effect in their assessment of 0708-0 I I0/79/0~00-0086$02.00v )I 979 Medical Education
Summary
86
Clinicul teaching
colleagues’ teaching by judging the effectiveness of each other’s teaching performance on the basis of medical knowledge (Cotsonas & Kaiser, 1963). Furthermore, physicians who are used as models are often unaware of this. They are researchers and administrators, individuals whose knowledge makes them expert in a specific specialty (Elrick, 1967). In their role as teacher, they often exemplify ideals of knowledge and performance without giving equal consideration to the understanding of patients as people (Engel, 1971a). Since teachers stress factual knowledge in medical schools, the patient is also viewed as a n abstraction rather than a person. Patients are rarely involved in the discussion of treatment and prognosis except as silent and often apprehensive observers. Placed in a situation where they cannot meaningfully communicate with students, they reserve their questions and concerns for nurses. The effect on students limits the possibility of their acquiring skills and knowledge for development of the doctor-patient relationship (Pilowsky, 1973). Finally, because of the emphasis on didactic teaching of facts, interaction between doctor and patient and the diagnostic process have been neglected. These components of clinical teaching and learning have been labelled as ‘art’. However, a body of literature has emerged indicating that clinical teaching and learning is being thought about and studied in some medical schools. For a systematic consideration of the elements in clinical teaching, it will be helpful to synthesize the components of effective clinical teaching as described in this literature.
What is ‘good’ clinical teaching? Three sources provide criteria for effective clinical teaching. The opinion of experts usually reflects intensive and prolonged inquiry into a subject. Student assessment of clinical teaching provides a perspective from the consumer’s point of view. Finally, observational studies of clinical teaching reflect criteria for good teaching for researchers.
(I
)
Expert opinioii
The ‘expert’ is defined as an individual who has grappled with the problem of understanding clinical teaching. A working party of the Royal College of General Practitioners ( I 972) identified four goals of clinical teaching: to help students integrate
87
and assimilate factual information in problem solving; to teach manual skills performance; to demonstrate interpersonal skills ; and to provide students with the opportunity for self-understanding. These goals concentrate on logical processes in problem-solving and decision-making, on interpersonal interactions and relationships, and on development of practical skills. Dudley (1969) considered the problem facing clinical teachers seeking to understand and teach the diagnostic process. The clinical teacher needs first to recognize this process apart from the technique of collecting information, and distinct from the imparting of factual information. The diagnostic process is a separate operation having its set of functions which can be applied to the field of medicine. Clinical teachers have rarely given thought to the process they use to make their clinical judgments. Effective teaching of the process of clinical diagnosis calls for teachers to be able to articulate their own cognitive processes when making a diagnosis. Furthermore, students should be taught some theory of diagnosis so that they might engage in effective problem-solving and decision-making (McWhinney, 1972). Another element in clinical teaching and learning is the use of clinical language. Often students have not yet developed a fluency in speaking to patients. This shortcoming requires that clinical teaching focuses on the patient rather than the disease, and that students be introduced to techniques for collecting data by gradual involvement in the clinical setting (Engel, 1971a). To interact effectively with patients, students must have some knowledge of themselves. Among four styles of teaching identified by the Royal College of General Practitioners, the counselling style was mosl pertinent for the task of self-knowledge. Although alien to most teachers, this counselling style provides the students not only with the opportunity to practice problem-solving skills, but allows them to explore their own feelings and attitudes toward a patient. Often students are unaware of their feelings toward patients or even toward the teacher. This method of teaching helps students ‘get in touch’ with their own personal difficulties in relating to people. (2) Student perception of teuching Students are more discriminating than their teachers in that they do not judge effective teaching
88
Annette M . Yonke
on the basis of medical knowledge alone. They also recognize the attitude of the teacher toward patients and students, as well as the use of certain teaching techniques (Cotsonas & Kaiser, 1963). Students perceive several factors as helpful in facilitating clinical learning. These factors in order of preference are : encouraging active student participation; positive attitudes toward teaching on the part of teachers; emphasis on applied problemsolving rather than on factual material; studentcentred instructional strategies; humanistic orientation; and emphasis on references and research results (Stritter et at. 1975). Another study described student views as important contributants to effective clinical teaching: active student participation; a student orientation in teaching; close supervision and evaluation of students; teacher’s attitude toward teaching; emphasis on problem solving; and studentcentred instructional strategy (Miller, 1976). Results of a third study on clinical clerkship activities indicated that of ten modes of learning observed, three were most effective: instructed learning (performing procedures and presenting cases under supervision); practice; and team problem solving. Methods which received the highest rating were those involving students. Lowest ratings were given to didactic and observational learning, both passive methods of learning (Byrne & Cohen, 1973).
(3) Observational studies
Questions framed by researchers in reporting results of their studies on clinical teaching indicate their conception of good clinical teaching. In discussing their findings, Reichsman et at. (1964) reveal five criteria for effective clinical teaching: close supervision of students; integration of clinical medicine with didactic instruction; clarity of teaching; effective problem solving; and providing challenge to students. Another observational study on clinical teaching indicated that clinical teachers individualized models of ‘good’ teaching. Teachers evaluated other teachers on the basis of their own teaching style. The outcome of this study indicated the importance of teachers becoming aware of their own teaching methods. Participants learned to appreciate alternative styles and values in clinical teaching (Adams et al., 1974). The above criteria of effective teaching are as follows :
(1) It emphasizes problem-solving integrating basic science content with clinical method. This is effectively done by providing for student participation. (2) It develops a patient-centred rather than a disease orientation. (3) It develops awareness of teaching style in working with patients and students and understands the use of the diagnostic process to help students develop their own problem-solving methods. (4) Students are carefully supervised. ( 5 ) Teachers are outgoing, friendly and enjoy teaching. (6) Manual skills are taught. (7) Students are allowed to learn about themselves. (8) Readings and research interests are shared. Studies which report current practice and research in clinical programmes amplify the criteria for effective clinical teaching. Clinical programmes exemplifying ‘good’ clinical teaching
Effective teaching begins with teachers learning more about teaching. With regard to problemsolving as a method of teaching, Adams et al. (1974) report a short course for clinical teachers which simulated the problem-solving process for selfeducation and evaluation of the teachers themselves. The method for the course consisted of the group’s own involvement in the problem-solving process. The subject matter was the clinical teacher’s behaviour which was observed by peers. The group identified teaching styles, problem-solving styles and use of technical language. Participants discovered that they consistently used their ownmodel ofteaching to evaluate others. Adamsconcluded that the enquiry generated self-inquiry, a personal example of problem-solving and a greater awareness of differences in teaching styles. Morgan et af. (1972) described a ‘general clerkship’ course for students that was designed to teach the clinical approach to the patient. The course was designed because teaching of interviewing and physical examination skills received only secondary importance in the curriculum. The ‘general clerkship’ incorporated teaching innovations related to problem-solving and active student participation. Another example of a problem-solving approach
Clinical teaching
focused on teaching basic clinical skills of interviewing and a physical examination (Newble, 1973). Seven objectives were stated at the outset of the six week course. Upon completion of the course students were expected to perform specific clinical skills related to the objectives. The design of the course included ‘related activities’ or teaching methods which specified how objectives were to be accomplished. The assessment included student judgment of the course as well as teacher evaluation of students. With respect to the interactive aspects of the doctor-patient encounter, Goroll et al. (1974) reports the results of a study on the teaching of history taking for first year students in which the diagnosis focused on medical, psychological and social problems. In their interactions with patients students became responsibly involved with patients, who were impressed with the attention given to emotional aspects of their problem. Bloch (1975) describes a clinical course on death and dying where students met with a dying patient, kept a diary record, and attended weekly sessions with the instructor. The problem of close supervision of students is underscored by Weiner (1974). Engel (1 971b) also addresses the problem of supervision of students, questioning the case presentation as an optimal method of teaching. Despite its positive aspects, the case presentation has decided limitations when it comes to supervision and evaluation of students’ interactions with patients. The clinical teacher has limited data on which to judge the methods that students use to collect and evaluate information from patients. Engel proposes a group problemsolving approach where the student participants generate hypotheses, and the student and teacher who have worked up the patient act as resource persons. In this method students become actively and critically involved, and their work is more carefully supervised. Two other group problem-solving methods allow Sor close supervision of students. In the ‘general clerkship’ discussed above, provision is made for direct observation of students and use of tape recorders as students interview patients. In this group problem-solving and team-teaching situation, students are supervised by their peers and their teachers, their own assessment of themselves also being taken into account. These instructional methods of group problem-solving provide an alternative to case presentation, and also insure supervision of students.
89
Another component of good clinical teaching is the teacher’s attitude toward teaching. Gamble (1974) studied attitudes of practising doctors who were part time teachers teaching in the medical school. These doctors served in the roles of tutors. evaluators, advisors, and friends of students. All but one doctor indicated a willingness to repeat the experience. One of the problems in teachers’ attitudes is that doctors give low priority to teaching. Understanding the diagnostic process
Dudley (1970) writes that the clinical task of problem-solving is similar to the early stages of scientific thinking, in that the clinician continually formulates and tests hypotheses from the moment the patient presents. The process is based on deductive logic and on-going feedback until the problem is solved. From this description of the process, three areas relevant to the general task of problemsolving can be outlined : (i) ‘clinical systematics’ (the mental strategies for problem solving plus concepts used to formulate them), (ii) ‘clinical method’ (skills needed for transfer of information), and (iii) systematic ‘factual knowledge’ (key facts needed for correlation of information and frame of reference for data from patient). This type of taxonomic analysis ‘exteriorizes the educational problem and may thus permit the speification of a syllabus in concrete terms rather than as a series of pious hope’. Students learning about themselves
The question of helping students to learn about themselves is rarely raised as an issue for clinical teaching. The problem has implications for students with respect to their roles as compassionate and technically competent clinicians. Kimball (1973) hypothesizes that ‘the process of medical education has the potential of providing for a greater growth and development and hence, humanization of the individual than other experiences afforded to mankind’. Kimball’s research indicates that students experience emotional difficulties related to resolving adolescent conflicts of separation from parents and attempting to establish satisfactory adult roles. They
90
Annette
are uncertain about their ultimate medical career choices. They identify with the patient rather than the doctor. It would seem that clinical teachers could help students with their own feelings and moral and ethical issues in the immediate clinical setting.
Incidental learning Since current methods of teaching generally focus on acquisition of medical knowledge, it is of note to identify studies which suggest that students do not acquire significant knowledge during their clerkships. Levine & Forman (1975) found that a substantial portion of the cognitive information required for success in the clinical years was acquired prior to students’ entry into the clerkship. Morse et al. (1975) found that contrary to teachers’ impressions students are better prepared cognitively after having had prior clerkship experience. Students with previous hospital experience learn to cope with hospital procedure, to obtain information from patients, to present patients to teachers on rounds, and to perform various procedures. Atkinson (1 976) believes students gain insight into the division of labour, hierarchy, social distance, organizational power, and control.
Conclusion In attempting to identify ‘good’ clinical teaching, four major components emerge: (i) integration of basic medical knowledge with problem-solving; (ii) interpersonal interaction; (iii) the diagnostic process as a separate cognitive process; and (iii) skills related to management of the patient. The techniques of teaching these components vary among teachers, but specific skills characterize effective teaching. Clinical teaching is clearly more complex. Because teaching and learning is usually an interactive process, it is difficult to separate the act of teaching from student learning. If the components of clinical teaching can clearly be identified and practised, then researchers will be able to determine the extent to which the practice of certain teaching skills does in fact influence student learning.
References ADAMS,W.R. et nl. (1964) A naturalistic study of teaching in a clinical clerkship. Journal of Medical Education, 39, 164.
M . Yoyke ADAMS,W.R. et al. (1974) Research in self-education for clinical teachers, Journal of Medical Education, 49, 1166. ATKINSON, P. (1976) Upstairs, downstairs: medical students in their first clinical year and their previous experience of work in hospitals. Medical Education, 10, 3. BASHOOK,P.G. (1976) A conceptual framework for measuring clinical problem-solving. Journal of Medical Education. 51, 109. BLOCH,S. (1975) A clinical course on death and dying for medical students. Journal of Medical Education, 50, 630. BYRNE, N. & COHEN, R . (1973) Observational study of clinical clerkship activities. Journal of Medical Education. 48, 919. N.I. & KAISER, H.F. (1963) Student evaluation of COTSONAS, clinical teaching. J(JUrfldof Medical Education, 38, 742. H.A.F. (1969) Tasks for clinicians: the diagnostic DUDLEY, process. Medical Journul of Australia, 1, 37. DUDLEY,H.A.F. (1970) Taxonomy of clinical educational objectives. British Journal of Medical Education. 4, 13. ELRICK,H. (1967) The clinical education of the medical student. Journal of Medical Education, 42, 453. E N ~ ~ G.L. E L , (1971a) Care and feeding of the medical student: the foundation for professional competence. Journal of the American Medical Association, 215, 1135. ENGEL,G.L. (1971b) The deficiencies of the case presentation as a method of clinical teaching. N e w England Journal of’ Medicine, 284, 20. GAMBLE, T.E. (1974) The practicing physician’s involvement in the training of medical students. Journal of Medical Education, 49, 331. A.H. et at. (1974) Teaching the clinical interview: GOROLL, an experiment with first-year students. Journal of Medical Education, 49, 957. KIMBALL, C.P. (1973) Medical education as a humanizing process. Journal of Medical Education, 48, 71. LEviNE, H.G. & FORMAN, P.M. (1975) The development of cognitive knowledge in clinical clerkships. Journal of Medical Education, 50, 27 I . MCWHINNEY, I . R . (1972) Problem-solving and decisionmaking in primary medical practice. froc. Royal Soc. Med., 65, 34. MILLER, M.D. (1976) Student Evaluation of Clinical Teaching. Paper presented to the HPE Special Interest Group, American Educational Research Association, Annual Convention, San Francisco, California. MORGAN,W.L. et a / . (1972) General clerkship: a course designed to teach the clinical approach to the patient. Journal of Medical Education, 41, 556. MORSE, P.K. et al. (1975) Effect of previous clerkship experience on readiness for basic medical clerkship. Journal of Medical Education, 50. 199. NEWBLE,D.1. (1973) Teaching basic clinical skills and problem-solving to fifth year medical students. Medical Journal of Australia, 2, 1094. I. (1973) The student, the patient and his illness: PILOWSKY, the ethics of clinical teaching. Medical Journal of Aiistralia, 1, 858. RtlCHSMAN, F. (4 a / . (1964) Observations of undergraduate clinical teaching in action. Journal of Medical Edncatioti. 39, 147. ROYALCOLLECEOF GENERAL PRACTITIONERS (1972) The Future General Proctitioner: Learning and Teacliing. Royal College of General Practitioners, London. STRITTER, F.T. et al. (1 975) Clinical teaching re-examined. Journal of Medical Education, 50, 876. WEINER,S.L. (1974) Ward rounds revisited: the validity of the data base. JournalofMerlical Education, 49, 351.
The art and science of clinical teaching A N N E T T E M. Y O N K E Center f o r Educational Dcvdopment. University of Illinois Medical Center, C l i i c ~ g oIllinois ,
using the same methods of several generations ago. However, in this age of student influence in the A review of the literature on clinical teaching indiacademic world, students’ criticism of teaching cslls cates that medical schools emphasize didactic for examination of practices long taken for granted. teaching of facts. Interpersonal skills, problem The purpose of this review is to identify the skills solving skills and cultivation of attitudes are for effective clinical teaching; to describe programmes neglected. However, the literature also describes where innovative clinical teaching occurs; to indicate the skills of ‘good’ clinical teachers, and enumerates some of the problems in clinical teaching; and to them. Programmes attempting to develop students’ recommend some areas for further practice and interpersonal skills and problem solving skills are research in clinical teaching. reported. Finally, areas for further practice and study The literature on clinical teaching in the last in clinical teaching are recommended. decade emphasizes factual information and neglect of emphasis o n the patient as deficiencies in clinical Keywords: TEACHING/*methOdS; ’CLINICAL teaching. Factual information has traditionally been assessed in determining the quality of student learnSKILLS;*EDUCATION, MEDICAL, UNDERGRADUATE; ing (Bashook, 1976). Examinations focus on the PROBLEMSOLVING; EVALUATION STUDIES;DIAGmaterial students learn rather than on their diagnostic NOSIS; SELF PERCEPTION and interpersonal skills. As a result students do not learn about psychological or sociological aspects of Introduction patient care (Goroll, 1974). Clinical teachers are seen to be preoccupied with didactic teaching. Clinical teachers in medical schools find it difficult Ward rounds are didactic experiences conducted to identify the specific steps and skills they use in without patients, often occurring not at the bedside teaching. They also admit giving limited thought but in a meeting room where the patient is not seen to the process they use to arrive at a diagnosis of but merely discussed. When bedside rounds do occur, disease. When questioned about their skills, they students are passive onlookers. In clinical condescribe their teaching and the process of diagnosis ferences teachers lecture to only a handful of students as ‘art’. As successful teachers they practise their with no question and answer period. Seminars differ teaching craft and perform their problem-solving from such sessions in that students, not the instrucintuitively, Their students learn through the same tor, lecture (Reichsman et a/.,1964). Since clinical mode of intuition and inspiration-not altogether teachers are still operating under the misguided an undesirable method of learning. view that students should see as many interesting But ‘born teachers’ number only a few among the cases as possible, little attempt has been made to ranks of clinical teachers in medical shook. Those teach and assess clinical interviewing and physical having less artistry perform their teaching tasks examination skills other than in psychiatry (Newble, Correspondence: Dr Annette M. Yonke, Center f o r 1973). Educational Development, University of Illinois Medical The emphasis on factual information is further Center, 808 South Wood Street, Room 973, Chicago, Illinois, 60612, U . S . A . confirmed by research findings that indicate clinical teachers create a halo effect in their assessment of 0708-0 I I0/79/0~00-0086$02.00v )I 979 Medical Education
Summary
86
Clinicul teaching
colleagues’ teaching by judging the effectiveness of each other’s teaching performance on the basis of medical knowledge (Cotsonas & Kaiser, 1963). Furthermore, physicians who are used as models are often unaware of this. They are researchers and administrators, individuals whose knowledge makes them expert in a specific specialty (Elrick, 1967). In their role as teacher, they often exemplify ideals of knowledge and performance without giving equal consideration to the understanding of patients as people (Engel, 1971a). Since teachers stress factual knowledge in medical schools, the patient is also viewed as a n abstraction rather than a person. Patients are rarely involved in the discussion of treatment and prognosis except as silent and often apprehensive observers. Placed in a situation where they cannot meaningfully communicate with students, they reserve their questions and concerns for nurses. The effect on students limits the possibility of their acquiring skills and knowledge for development of the doctor-patient relationship (Pilowsky, 1973). Finally, because of the emphasis on didactic teaching of facts, interaction between doctor and patient and the diagnostic process have been neglected. These components of clinical teaching and learning have been labelled as ‘art’. However, a body of literature has emerged indicating that clinical teaching and learning is being thought about and studied in some medical schools. For a systematic consideration of the elements in clinical teaching, it will be helpful to synthesize the components of effective clinical teaching as described in this literature.
What is ‘good’ clinical teaching? Three sources provide criteria for effective clinical teaching. The opinion of experts usually reflects intensive and prolonged inquiry into a subject. Student assessment of clinical teaching provides a perspective from the consumer’s point of view. Finally, observational studies of clinical teaching reflect criteria for good teaching for researchers.
(I
)
Expert opinioii
The ‘expert’ is defined as an individual who has grappled with the problem of understanding clinical teaching. A working party of the Royal College of General Practitioners ( I 972) identified four goals of clinical teaching: to help students integrate
87
and assimilate factual information in problem solving; to teach manual skills performance; to demonstrate interpersonal skills ; and to provide students with the opportunity for self-understanding. These goals concentrate on logical processes in problem-solving and decision-making, on interpersonal interactions and relationships, and on development of practical skills. Dudley (1969) considered the problem facing clinical teachers seeking to understand and teach the diagnostic process. The clinical teacher needs first to recognize this process apart from the technique of collecting information, and distinct from the imparting of factual information. The diagnostic process is a separate operation having its set of functions which can be applied to the field of medicine. Clinical teachers have rarely given thought to the process they use to make their clinical judgments. Effective teaching of the process of clinical diagnosis calls for teachers to be able to articulate their own cognitive processes when making a diagnosis. Furthermore, students should be taught some theory of diagnosis so that they might engage in effective problem-solving and decision-making (McWhinney, 1972). Another element in clinical teaching and learning is the use of clinical language. Often students have not yet developed a fluency in speaking to patients. This shortcoming requires that clinical teaching focuses on the patient rather than the disease, and that students be introduced to techniques for collecting data by gradual involvement in the clinical setting (Engel, 1971a). To interact effectively with patients, students must have some knowledge of themselves. Among four styles of teaching identified by the Royal College of General Practitioners, the counselling style was mosl pertinent for the task of self-knowledge. Although alien to most teachers, this counselling style provides the students not only with the opportunity to practice problem-solving skills, but allows them to explore their own feelings and attitudes toward a patient. Often students are unaware of their feelings toward patients or even toward the teacher. This method of teaching helps students ‘get in touch’ with their own personal difficulties in relating to people. (2) Student perception of teuching Students are more discriminating than their teachers in that they do not judge effective teaching
88
Annette M . Yonke
on the basis of medical knowledge alone. They also recognize the attitude of the teacher toward patients and students, as well as the use of certain teaching techniques (Cotsonas & Kaiser, 1963). Students perceive several factors as helpful in facilitating clinical learning. These factors in order of preference are : encouraging active student participation; positive attitudes toward teaching on the part of teachers; emphasis on applied problemsolving rather than on factual material; studentcentred instructional strategies; humanistic orientation; and emphasis on references and research results (Stritter et at. 1975). Another study described student views as important contributants to effective clinical teaching: active student participation; a student orientation in teaching; close supervision and evaluation of students; teacher’s attitude toward teaching; emphasis on problem solving; and studentcentred instructional strategy (Miller, 1976). Results of a third study on clinical clerkship activities indicated that of ten modes of learning observed, three were most effective: instructed learning (performing procedures and presenting cases under supervision); practice; and team problem solving. Methods which received the highest rating were those involving students. Lowest ratings were given to didactic and observational learning, both passive methods of learning (Byrne & Cohen, 1973).
(3) Observational studies
Questions framed by researchers in reporting results of their studies on clinical teaching indicate their conception of good clinical teaching. In discussing their findings, Reichsman et at. (1964) reveal five criteria for effective clinical teaching: close supervision of students; integration of clinical medicine with didactic instruction; clarity of teaching; effective problem solving; and providing challenge to students. Another observational study on clinical teaching indicated that clinical teachers individualized models of ‘good’ teaching. Teachers evaluated other teachers on the basis of their own teaching style. The outcome of this study indicated the importance of teachers becoming aware of their own teaching methods. Participants learned to appreciate alternative styles and values in clinical teaching (Adams et al., 1974). The above criteria of effective teaching are as follows :
(1) It emphasizes problem-solving integrating basic science content with clinical method. This is effectively done by providing for student participation. (2) It develops a patient-centred rather than a disease orientation. (3) It develops awareness of teaching style in working with patients and students and understands the use of the diagnostic process to help students develop their own problem-solving methods. (4) Students are carefully supervised. ( 5 ) Teachers are outgoing, friendly and enjoy teaching. (6) Manual skills are taught. (7) Students are allowed to learn about themselves. (8) Readings and research interests are shared. Studies which report current practice and research in clinical programmes amplify the criteria for effective clinical teaching. Clinical programmes exemplifying ‘good’ clinical teaching
Effective teaching begins with teachers learning more about teaching. With regard to problemsolving as a method of teaching, Adams et al. (1974) report a short course for clinical teachers which simulated the problem-solving process for selfeducation and evaluation of the teachers themselves. The method for the course consisted of the group’s own involvement in the problem-solving process. The subject matter was the clinical teacher’s behaviour which was observed by peers. The group identified teaching styles, problem-solving styles and use of technical language. Participants discovered that they consistently used their ownmodel ofteaching to evaluate others. Adamsconcluded that the enquiry generated self-inquiry, a personal example of problem-solving and a greater awareness of differences in teaching styles. Morgan et af. (1972) described a ‘general clerkship’ course for students that was designed to teach the clinical approach to the patient. The course was designed because teaching of interviewing and physical examination skills received only secondary importance in the curriculum. The ‘general clerkship’ incorporated teaching innovations related to problem-solving and active student participation. Another example of a problem-solving approach
Clinical teaching
focused on teaching basic clinical skills of interviewing and a physical examination (Newble, 1973). Seven objectives were stated at the outset of the six week course. Upon completion of the course students were expected to perform specific clinical skills related to the objectives. The design of the course included ‘related activities’ or teaching methods which specified how objectives were to be accomplished. The assessment included student judgment of the course as well as teacher evaluation of students. With respect to the interactive aspects of the doctor-patient encounter, Goroll et al. (1974) reports the results of a study on the teaching of history taking for first year students in which the diagnosis focused on medical, psychological and social problems. In their interactions with patients students became responsibly involved with patients, who were impressed with the attention given to emotional aspects of their problem. Bloch (1975) describes a clinical course on death and dying where students met with a dying patient, kept a diary record, and attended weekly sessions with the instructor. The problem of close supervision of students is underscored by Weiner (1974). Engel (1 971b) also addresses the problem of supervision of students, questioning the case presentation as an optimal method of teaching. Despite its positive aspects, the case presentation has decided limitations when it comes to supervision and evaluation of students’ interactions with patients. The clinical teacher has limited data on which to judge the methods that students use to collect and evaluate information from patients. Engel proposes a group problemsolving approach where the student participants generate hypotheses, and the student and teacher who have worked up the patient act as resource persons. In this method students become actively and critically involved, and their work is more carefully supervised. Two other group problem-solving methods allow Sor close supervision of students. In the ‘general clerkship’ discussed above, provision is made for direct observation of students and use of tape recorders as students interview patients. In this group problem-solving and team-teaching situation, students are supervised by their peers and their teachers, their own assessment of themselves also being taken into account. These instructional methods of group problem-solving provide an alternative to case presentation, and also insure supervision of students.
89
Another component of good clinical teaching is the teacher’s attitude toward teaching. Gamble (1974) studied attitudes of practising doctors who were part time teachers teaching in the medical school. These doctors served in the roles of tutors. evaluators, advisors, and friends of students. All but one doctor indicated a willingness to repeat the experience. One of the problems in teachers’ attitudes is that doctors give low priority to teaching. Understanding the diagnostic process
Dudley (1970) writes that the clinical task of problem-solving is similar to the early stages of scientific thinking, in that the clinician continually formulates and tests hypotheses from the moment the patient presents. The process is based on deductive logic and on-going feedback until the problem is solved. From this description of the process, three areas relevant to the general task of problemsolving can be outlined : (i) ‘clinical systematics’ (the mental strategies for problem solving plus concepts used to formulate them), (ii) ‘clinical method’ (skills needed for transfer of information), and (iii) systematic ‘factual knowledge’ (key facts needed for correlation of information and frame of reference for data from patient). This type of taxonomic analysis ‘exteriorizes the educational problem and may thus permit the speification of a syllabus in concrete terms rather than as a series of pious hope’. Students learning about themselves
The question of helping students to learn about themselves is rarely raised as an issue for clinical teaching. The problem has implications for students with respect to their roles as compassionate and technically competent clinicians. Kimball (1973) hypothesizes that ‘the process of medical education has the potential of providing for a greater growth and development and hence, humanization of the individual than other experiences afforded to mankind’. Kimball’s research indicates that students experience emotional difficulties related to resolving adolescent conflicts of separation from parents and attempting to establish satisfactory adult roles. They
90
Annette
are uncertain about their ultimate medical career choices. They identify with the patient rather than the doctor. It would seem that clinical teachers could help students with their own feelings and moral and ethical issues in the immediate clinical setting.
Incidental learning Since current methods of teaching generally focus on acquisition of medical knowledge, it is of note to identify studies which suggest that students do not acquire significant knowledge during their clerkships. Levine & Forman (1975) found that a substantial portion of the cognitive information required for success in the clinical years was acquired prior to students’ entry into the clerkship. Morse et al. (1975) found that contrary to teachers’ impressions students are better prepared cognitively after having had prior clerkship experience. Students with previous hospital experience learn to cope with hospital procedure, to obtain information from patients, to present patients to teachers on rounds, and to perform various procedures. Atkinson (1 976) believes students gain insight into the division of labour, hierarchy, social distance, organizational power, and control.
Conclusion In attempting to identify ‘good’ clinical teaching, four major components emerge: (i) integration of basic medical knowledge with problem-solving; (ii) interpersonal interaction; (iii) the diagnostic process as a separate cognitive process; and (iii) skills related to management of the patient. The techniques of teaching these components vary among teachers, but specific skills characterize effective teaching. Clinical teaching is clearly more complex. Because teaching and learning is usually an interactive process, it is difficult to separate the act of teaching from student learning. If the components of clinical teaching can clearly be identified and practised, then researchers will be able to determine the extent to which the practice of certain teaching skills does in fact influence student learning.
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