Clinical Learning

Teaching in the clinical environment i.e. learning with real patients with real medical problems, is a central part of medical education.
It is also a very challenging domain to teach in, with a huge number of pressures that can impair its quality.
A good understanding of these pressures and techniques to optimise teaching in this environment can help make the most of a very valuable educational resource.

The AMEE guide by Ramani and Leinster note some common problems with teaching in the clinical context:

Time pressures - inadequate time given to reflection and discussion, as well as direct observation of students. May also prevent any teaching occurring at all if clinical demand is high.
Unplanned - the variable nature of clinical work means that teaching will be reactive, and thus with minimal preparation time. It may also be very different from a current learning theme or curriculum.
Wide student range - the clinical environment often involves a wide range of specialties and experience, thus making pitching the teaching at the right level a challenge.
Suboptimal physical environment - a busy, noisy ward may make the actual teaching process harder. Teaching in front of patients may also provide barriers to teaching e.g. reticence to discuss certain topics, reticence to admit ignorance.

Two useful models can be employed to overcome such challenges:

Stanford faculty development model
The one-minute preceptor

Stanford Faculty Development Model

This describes 7 key categories of teaching in the clinical environment which are important to consider.

Promoting a positive learning environment - it is important to set the tone of the learning environment right, to positively encourage learning and have the degree of safety to ask questions.
Control of session - it is important to consider the focus and pace of the session to ensure it is efficient.
Communication of goals - a clear understanding of the intended learning outcomes helps provide a structure for the session
Promoting understanding and retention - it is important to specifically think about the teaching approach that will allow the learner to meaningfully engage with the learning process, and thus get the optimal benefit from it.
Evaluation - this allows consideration of the student against the learning objectives to help assess the effectiveness of the session, and help guide further teaching.
Feedback - provision of feedback to learners helps them with the cyclical learning process.
Promoting self-directed learning - this aims to encourage further learning beyond the scope of the session.

The One-Minute Preceptor

This is a microskills model for teaching, providing a framework for optimising the educational benefit of clinical learning opportunities.
The idea is that they can be adjusted to fit the available time, however short:

Get a commitment - promote a safe learning environment to get the learner to comit to a decision on the topic in question e.g. management pla, diagnosis
Probe for supporting evidence - encourage the learner to verbalise their rational for this, and to discuss it with them, either confirming or refuting.
Teaching general rules - use the clinical example to introduce an important clinical rule/approach
Reinforcing what was done well - this should be specific and is an important part to build the students confidence
Correcting mistakes - challenging to do, but important for learning. Encouraging the student to reflect and provide the answer can be the best approach. If being done by the teacher, being specific is again very important.

Links & Resources

Ramani, S. Leinster, S. AMEE Guide no. 34: Teaching in the clinical environment. Medical Teacher. 2008. 30(4):347-364. Available at: https://www.ncbi.nlm.nih.gov/pubmed/18569655
Bleakley, A. Bligh, J. Students learning from patients: let's get real in medical education. Adv Health Sci Educ Theory Pract. 2008. 13(1):89-107. Available at: https://www.ncbi.nlm.nih.gov/pubmed/17075690