Indian Journal of Medical Specialities

EDITORIAL
Year
: 2022  |  Volume : 13  |  Issue : 2  |  Page : 73--76

Clinical teaching: How to make it effective


Aruna Nigam 
 Department of Obstetrics and Gynaecology, Hamdard Institute of Medical Sciences and Research, Jamia Hamdard, New Delhi, India

Correspondence Address:
Dr. Aruna Nigam
Department of Obstetrics and Gynaecology, Hamdard Institute of Medical Sciences and Research, Jamia Hamdard, New Delhi
India




How to cite this article:
Nigam A. Clinical teaching: How to make it effective.Indian J Med Spec 2022;13:73-76


How to cite this URL:
Nigam A. Clinical teaching: How to make it effective. Indian J Med Spec [serial online] 2022 [cited 2022 May 28 ];13:73-76
Available from: http://www.ijms.in/text.asp?2022/13/2/73/341177


Full Text



“Tell me I forget, teach me and I may remember, involve me and I learn.”

-Benjamin Franklin

Changing paradigm in the education strategies, easy availability of educational resources, demanding students as well as patient, the concept of adult learning and recently introduction of competency-based medical education (CBME) has changed the teaching-learning - assessment trilogy. The goals and roles set by the Medical Council of India, now the National Medical Council (NMC) for Indian Medical Graduate are clinician, leader, member of the health care team, communicator, lifelong learner, and professional. The new CBME-based program has been carved intricately to teach all these roles to an undergraduate MBBS student effectively.

Clinical teaching is an integral part of the MBBS curriculum and it deals with all three domains: Cognitive, psychomotor, and affective. Effective clinical teaching makes the student an avid learner. There are two terms – “clinical teaching” and “teaching in clinics.” Just shifting a word from right to left has made a difference as teaching in clinics is related entirely with the patient or on the patient but clinical teaching can be in clinics/skill labs/demonstration rooms and without patients.

Educating undergraduate students and residents in clinics is a challenge as simultaneously imparting quality care to the patient, maintaining efficiency, and incorporating meaningful education have to go hand in hand. Common barriers encountered in effective clinical teaching are the busy clinical schedule of the teachers, lack of financial support from administration, scarcity of space in the out-patient departments (OPD), wards and operation theaters and many a times lack of patients, especially in private institutions.

There are various methods described in the literature with respect to clinical teaching.

Learner doctor methodPeyton's four-step approachOne-minute preceptorSNAPPSUse of Teaching AssociateAUNT MINNIEActivated demonstrationRole play and video demonstration.

All of these methods are good but we need to adopt the best method according to our educational and hospital resources, topic, time, and level of the student.

 Learner Doctor Method



It is a learning program that is part of the clinical rotations of the MBBS course and is designed to provide medical students a longitudinal immersive learning experience in the care of patients in a supervised setting. This is described in the NMC Gazette notification.[1]

The goals of the method are to provide students experience with longitudinal patient care, functioning as part of health care team and providing hands-on care of patients in the inpatient and OPDs. As soon as the student's clinical postings start after the first phase, he/she starts functioning as part of one of the units in the department, functioning as supervised members of the healthcare team and is involved in patient care. They will be assigned patients, be it in the OPD or the wards, which they shall interview, examine, and work up under supervision. He/she enters work allotted in the document which is in the form of logbook and is assessed formatively by supervising physician. These cases will be presented to the supervising consultant during the rounds on the designated days. They will remain with the admission team until 6 PM on the admission day except during designated class hours. They document patient encounters and learnings appropriate for the level of training in a portfolio or annexure to logbook which will be assessed formatively by supervising consultant and feedback from the consultant and other members, i.e., residents will be provided. To ensure sincerity and proper learning these logbooks and supporting case records are rechecked or submitted before examination in the particular subject.

Learning appropriate for the level of training can be divided as under:

First phase: Students are introduced to the hospital environment by early clinical exposure to understand the perspective of illnessSecond phase: Students are taught how to take history and perform physical examination, how to assess change in clinical status of a patient during daily rounds, how to communicate with the patient in an effective mannerThird phase part 1: In addition to the above, the choice of investigations and basic procedures required according to clinical scenario and continuity of care are discussedThird phase part 2: In addition to the above, decision-making, management, and outcomes are emphasized.

[Table 1] describes examples of few competencies to be allotted during the clinical posting in the obstetrics and gynaecology department.{Table 1}

Although this is a good method of involving the student in the patient care and give them first hand experience on all the aspects but there are many caveats:

Patient might not be ready for the student to be a part of care and may not cooperate: Proper consent and patient's autonomy to be respectedInstitutional policy might hinder the teaching in students having access to recordsStudent might go beyond their assigned duties to learn and perform independentlyPatients might misbehave with studentStudent might take advantage of clinical posting in not attending scheduled classesProfessional identity of the student might hinder in getting the consent for examination as most of the times hearing the term 'medical student', patients don't give them importance. The student identity can be labeled as “student physician” or “student doctor” for healthy work environment.

 Peyton's Four-Step Approach



Peyton's four-step approach[2] is a very good approach whenever we are teaching skills to the student on patient/dummies/standardized patients. It has 4 steps:

Demonstration: Here, the skill is performed by the trainer without speaking anything so as to see what the student can interpret on her ownDeconstruction: As a second step trainer describes and demonstrates the skill in a similar sequential manner slowly to improve the understanding. Here the skill can be divided into parts to further simplifyComprehension: In the third step, trainer performs the skill on the instruction of student so as to see what student understood and interpreted. The student describes every step of the skill whereupon the teacher performs on instructionExecution: In the last step, trainee performs the step with description simultaneously.

It has been found in studies that third step is the most important of all in the learning process.[2] In this approach, one can use video demonstration in first 2 steps. Various studies have authenticated the usefulness of this approach while teaching various skills.

 One Minute Preceptor



This strategy has been introduced in 1990 for effective teaching in clinics by using five microskills.[3]

Get a commitmentProbe for supporting evidenceTeach general rulesReinforce what was done rightCorrect mistakes.

To start with, ask the students to summarize the case in few lines and then get a commitment by asking them “what they want to do.” Thereafter, ask for the supporting evidence for their statement. Teach them general principles for the disease (tell them source of further learning) and encourage them whatever they have done right, this will make them more involved in the case and at the end tell them their mistakes which will act as feedback for them.

 SNAPPS Method



SNAPPS method[4] uses the cognitive and reflective properties. SNAPPS stands for:

Summarize the relevant history and physical findings in 2–3 minNarrow the differential: Likely? Relevant? To two or threeAnalyze the differential diagnosis.

The first three steps give an idea about the thought process of student

Probe the consultant by asking about problems and other approachesPlan patient management with studentSelect a case-related learning issue for self-directed learning.

 Use of Teaching Associate



This is a common method employed in Western countries, especially in gynecology for teaching pelvic examination and male examination. These are trained paid individuals who give feedback to the students from the patient's perspective. The routinely used teaching associates are

Physical Exam Teaching Associated: These are the individuals (non-medical persons) who are trained to teach the techniques of basic physical examination (abdominal, neurology, cardiovascular and pulmonary)Genitourinary teaching associates (GUTA): These are the individuals who allow the trainee to perform the gender-specific physical examination, i.e., vaginal examination or rectal examination, etc., on their body. These persons are trained regarding the specific examinations and protocols so that when trainees examine, they can show them the right way.

A metanalysis have found that female pelvic examination taught on Gynecology teaching associate (GTA) improves the competence and confidence level of the undergraduate students compared to mannequin-based teaching.[5] A randomized controlled trial “TARGET' where teaching associates randomized to evaluate the effectiveness of GTA-taught pelvic examination versus Traditional teaching using mannequins, also proved the efficacy of GTA in teaching pelvic examination skills.[6]

 “AUNT MINNIE” Method - The Value of Pattern Recognition



This is good in radiology teaching. The concept is “If the lady across the street walks like your Aunt Minnie and dresses like your Aunt Minnie, she probably is your Aunt Minnie.” In this method, 4 steps have been prescribed:[7]

Presentation of chief complaint and presumptive diagnosisStudent begins a write-up and preceptor evaluates the patientPreceptor discusses the case with the studentPreceptor reviews and signs medical records.

 Activated Demonstration



Teaching psychomotor skills requires place, demonstration, supervision, and feedback, to make the learner perform first in simulated environment and then in real-life situations. The basic steps are enumerated:

Assess student's relevant knowledgeDetermine what the student should learn from the skill demonstrationGuidance for student participation during skill demonstrationDemonstrate the clinical skillDiscuss learning points with the studentSet an agenda for future learning opportunities.

 Role Play and Video Demonstration



Roleplay is an important method to address the affective domain. This method is commonly used to teach counseling in various scenarios, i.e., discussing the treatment modality with cancer patients or contraception counseling. Video demonstrations are used for teaching psychomotor skills, especially where the demonstration of the live procedure is not possible. As discussed above, video demonstration can be used for the first 2 steps of Peyton's approach.

 Conclusion



There are various ways of clinical teaching and many more have been described in the literature. No one method is the best. One can choose the apt method according to the feasibility. The ultimate aim of effective clinical teaching is effective learning by the student to make them a competent physicians. Feedback forms an important component of all methods. Clinical teaching and assessment should be properly aligned for appropriate learning outcomes.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.

References

1Board of Governors in supersession of Medical Council of India. Amendment Notification, Gazette of India; November 04, 2019; Available from: https://www.nmc.org.in/ActivitiWebClient/open/getDocument?path=/Documents/Public/Portal/Gazette/GME-06.11.2019.pdf. [Last accessed on 2022 Jan 28].
2Krautter M, Dittrich R, Safi A, Krautter J, Maatouk I, Moeltner A, et al. Peyton's four-step approach: Differential effects of single instructional steps on procedural and memory performance – A clarification study. Adv Med Educ Pract 2015;6:399-406.
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5Cunningham AS, Blatt SD, Fuller PG, Weinberger HL. The art of precepting: Socrates or Aunt Minnie? Arch Pediatr Adolesc Med 1999;153:114-6.
6Smith PP, Choudhury S, Clark TJ. The effectiveness of gynaecological teaching associates in teaching pelvic examination: A systematic review and meta-analysis. Med Educ 2015;49:1197-206.
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