NASPGHAN/NESTLÉ NUTRITION INSTITUTE · Greg Kobak/Elaine Moustafellos/Alan ......

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NASPGHAN/NESTLÉ NUTRITION INSTITUTE FIRST YEAR PEDIATRIC GASTROENTEROLOGY FELLOWS CONFERENCE JANUARY 13 – 16, 2011 Course Director: Vicky Ng, MD and Co – Director: Daniel Kamin, MD 1

Transcript of NASPGHAN/NESTLÉ NUTRITION INSTITUTE · Greg Kobak/Elaine Moustafellos/Alan ......

Page 1: NASPGHAN/NESTLÉ NUTRITION INSTITUTE · Greg Kobak/Elaine Moustafellos/Alan ... dr_ghassan@hotmail.com Hamilton Canada Beasley Genie genie@peds ... York NY DeBosch Brian debosch_b@kids.wustl.edu

         

NASPGHAN/NESTLÉ NUTRITION INSTITUTE   

FIRST YEAR PEDIATRIC GASTROENTEROLOGY FELLOWS CONFERENCE 

 JANUARY 13 – 16, 2011 

   

Course Director: Vicky Ng, MD and  Co – Director: Daniel Kamin, MD 

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NASPGHAN/Nestle First Year Pediatric GI Fellows’ Conference 

January 13‐ 16, 2011  Dear Pediatric GI Fellows:  On behalf of NASPGHAN and the Nestle Nutrition Institute, a warm welcome to The Hilton Fort Lauderdale Beach Resort in sunny Ft. Lauderdale, Florida!  We remain thrilled that NASPGHAN and the Nestle Nutrition Institute have continued to partner over the last 9 years to bring together all the 1st Year Fellows of our North American Pediatric GI community.  This year, we have a record number of 109 first year fellows, and 15 faculty members!    We are most pleased that with each year, the membership of our 1st Year Fellows continues to grow – truly reflecting a positive effect you are having on your profession and future.  The goals of this conference are: 

1) To help you all develop strategies to get the most out of your fellowship training, with a particular focus on the choice of scholarly activities to pursue during the 2nd and 3rd fellowship training years; 

2) To introduce you to the various career paths available in our Profession, and start you thinking about what makes the most sense for you;  

3) To encourage a healthful approach to work and life balance, particularly the personal and professional issues that can contribute to burnout during fellowship; and 

4) To introduce you all to the larger pediatric GI community.   This is also a great opportunity to meet your peers and a rich variety of NASPGHAN faculty.  We encourage you to take full advantage of this unique opportunity.  Indeed, many of those whom you meet in these three days will become not only future colleagues, but future mentors, collaborators, and life‐long friends.  A full agenda has been carefully planned, and we hope the next 3 days will not only be educational and instructive, but will also transmit the enthusiasm of the great faculty who have come together.   We hope you take back home with you new ideas, new tools with which to examine them, and the exciting beginnings of a professional network of creative, budding gastroenterologists.   So……..get ready for some candid conversations, frolicking fun, and fantastic food! Sincerely, 

      

Vicky Ng, MD          José Saavedra, MD  

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2011 FIRST YEAR PEDIATRIC GASTROENTEROLOGY FELLOWS CONFERENCE TABLE OF CONTENTS 

 Welcome Letter  Faculty Listing  Program at a Glance  Small Group List  Choosing a Research Project Manu Sood, MD  Designing a Research Project Joshua Friedman, MD  Introduction to Research Ethics Daniel Kamin, MD  Writing and Presenting an Abstract for a National Meeting Valeria Cohran, MD  Breakfast with NASPGHAN and CDHNF Maria Perez, MD and Kathleen Schwarz, MD  Getting the Most Out of Your Fellowship Vicky Ng, MD  Choosing a Mentor Peter Lee, MD  How to Read and Critically Appraise Medical Literature Wallace Crandall, MD  Teaching Talk: Dos and Don’ts Michael Narkewicz, MD  Finding Balance Susan Gilmour, MD  Depression and Burnout in Medical Training Alan Leichtner, MD 

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FACULTY  Vicky Ng, MD, Director The Hospital for Sick Children Toronto, Ontario [email protected]  Daniel Kamin,MD, Co‐ Director Children's Hospital Boston Boston, MA [email protected]   Valeria Cohran, MD Children’s Memorial Hospital Chicago, IL vcohran@childrensmemorial .org  Wallace Crandall, MD Nationwide Children's Hospital Columbus, OH [email protected]  Joshua Friedman, MD The Children's Hospital of Philadelphia Philadelphia, PA [email protected]  Susan Gilmour, MD University of Alberta Edmonton, Alberta [email protected]  Gregory Kobak, MD Children's Hospital of The King's Daughters Norfolk, VA [email protected]  Peter Lee, MD Inova Pediatric Digestive Disease Centre Fairfax, VA [email protected]  Alan Leichtner, MD Children’s Hospital Boston Boston, MA [email protected]  

Elaine Moustafellos, MD Hackensack University Medical Centre Hackensack, NJ [email protected]  Michael Narkewicz, MD The Children's Hospital, Denver Denver, CO [email protected]  Maria Perez, MD Nationwide Children's Hospital Columbus, OH [email protected]  Pepe Saavedra, MD Nestle Nutrtion Institute Florham Park, NJ [email protected]  Kathleen Schwarz, MD Johns Hopkins Children’s Center Baltimore, MD [email protected]  Manu Sood, MD Children's Hospital of Wisconsin Milwaukee, WI [email protected] 

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Thursday, January 13 

16:00     Faculty Briefing      Vicky Ng/Daniel Kamin/Alan Leichtner  18:00    Reception  18:30    Dinner ‐ Seating in Groups –Welcome/Opening Remarks      Pepe Saavedra/Vicky Ng  19:30    Introductions     Faculty Leaders  20:00    GI Quiz Show – “Getting to Know You Exercise”  

Greg Kobak/Elaine Moustafellos/Alan Leichtner  

21:00    Goodnight! 

 

Friday, January 14 

07:30    Breakfast   08:00‐ 12:00  Session 1: Designing and Implementing Research Projects 

Moderator – Vicky Ng  

08:10    “Choosing a Research Topic”        Manu Sood  08:30    “Designing a Research Project”        Joshua Friedman                                     08:50    “Introduction to Research Ethics”        Daniel Kamin                                                                                             09:10    “Writing and Presenting an Abstract for a National Meeting”     Valeria Cohran      09:30    Nutrition Break   09:45    Introduction to Clinical Research Exercise     Daniel Kamin/Vicky Ng    10:00    Clinical Research Exercise 

2011 NASPGHAN First Year Fellows PROGRAM‐AT‐A‐GLANCE 

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   12:00    Lunch with Presentations:  “So You Think You Can Present?”                                          

    Hosts: Vicky Ng/Daniel Kamin         Judges:  Manu Sood/Valeria Cohran/Joshua Friedman  

14:00    Group Picture  14:30    Group Activity:  “Sand Castle Building”  

18:00    Reception   18:30    Dinner – Self‐Seating/Fellows Choose Tables: 

1) Private Practice  2) Scientist Track 3) Educator Track 4) Clinical Investigator/Translational Researcher Track 5) Administrator Track 6) Medicine in Industry 

  Saturday, January 15 

09:00    Breakfast with NASPGHAN & CDHNF      Maria Perez and Kathleen Schwarz  10:00‐12:00  Session 2: How to Approach Challenges and Seize Opportunities During Your 

Fellowship     Moderator – Daniel Kamin  10:05    “Getting the Most Out of Your Fellowship”     Vicky Ng  10:25    “Choosing a Mentor”     Peter Lee    10:45    “How to Critically Appraise the Literature You Read”     Wallace Crandall  11:05  Nutrition Break   11:20    “Giving a Great Teaching Talk” 

Michael Narkewicz  

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11:40    “Finding Balance”     Susan Gilmour  12:00    “Recognizing Burn Out During Fellowship” 

Alan Leichtner   12:15    Lunch 

Seating in Small Groups ‐ Discussions with Faculty Leaders  13:45    Free Time Options 

1) Sign up for 1:1 Time with Faculty Members  OR 

2) Activities on Own  18:00       Reception  18:30    Dinner and Awards  21:00    Entertainment     Sunday, January 16 

07:00    Breakfast   08:00    Fellow Feedback Session/Complete Surveys/ Wrap Up and Closing Remarks     Vicky Ng/Daniel Kamin  09:00    Faculty Feedback Session  11:00    Boxed lunches   

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Group 1 Gilmour Group 2 Crandall Group 3 Kamin

Last Name First Name E‐Mail City State/Country Last Name First Name E‐Mail City State/Country Last Name First Name E‐Mail City State/Country

Valentino Pamela [email protected] Toronto Canada Newland Catherine [email protected] Chicago IL Awai Hannah [email protected] San Diego CA

Jensen Melissa melissa‐j‐[email protected] Iowa City IA Hourigan Suchitra [email protected] Balitmore MD Burghardt Karolina [email protected] Toronto Canada

Bayardo Ramírez. Laura María [email protected] Guadalajara, Jalisco CP Mexico Neef Haley [email protected] Ann Arbor MI Powers Kerry Jo [email protected] New York NY

Mohanty Prita [email protected] Rochester NY Vittorio Jennifer [email protected] New York NY Van Arsdall Melissa [email protected] Houston TX

Choquette Monique [email protected] Cincinnati OH Mir Sabina [email protected] Sugarland TX Raizner Aileen [email protected] New Haven CT

Vadlamudi Narendra [email protected] Birmingham AL Rodriguez Jorge [email protected] Los Angeles CA Asai Akihiro [email protected] Chicago IL

O'Meara Kevin [email protected] North Bethesda MD Church Peter [email protected] Toronto Canada Hollon Justin [email protected] Ellicott City MD

Ng Kenneth [email protected] Bellaire TX Pant Chaitanya chaitanya‐[email protected] Oklahoma City OK Hashemi Ismaeel [email protected] Ann Arbor MI

Group 4 Kobak Group 5 Narkewicz Group 6 Cohran

Last Name First Name E‐Mail City State/Country Last Name First Name E‐Mail City State/Country Last Name First Name E‐Mail City State/Country

Yeh Ann Ming [email protected] Palo Alto CA Burgis Jennifer [email protected] Palo Alto CA Taketani Tami [email protected] Encinitas CA

Tapia Monge Dora Maria [email protected] Mexico City DF Mexico Gutierrez Glenda Karina [email protected] Delegacion CuahteMexico Gonzalez Berenice [email protected] Mexico City DF Mexico

Salehi Vesta [email protected] New York NY Co Maridine [email protected] Detroit MI Prince Esther [email protected] Brooklyn NY

Soler Dellys [email protected] Pittsburgh PA Jimenez Jennifer [email protected] Swarthmore PA Pham Yen [email protected] Houston TX

Rosen John [email protected] Chicago IL Sukkar Ghassan [email protected] Hamilton Canada Beasley Genie [email protected] Gainesville FL

Zaghloul Hazim [email protected] Royal Oak MI McFerron Brian [email protected] Indianapolis IN Turcotte Jean‐Francois [email protected] Edmonton Canada

Heintz D. Dyer [email protected] Dallas TX Rudolph Bryan [email protected] New York NY DeBosch Brian [email protected] Chesterfield MO

Lee Dale [email protected] Philadelphia PA

Group 7 Ng Group 8 Friedman Group 9 Moustafellos

Last Name First Name E‐Mail City State/Country Last Name First Name E‐Mail City State/Country Last Name First Name E‐Mail City State/Country

Nguyen Vivien [email protected] Los Angeles CA Lau Audrey [email protected] San Francisco CA Vahabnezhad Elaheh [email protected] Los Angeles CA

Bhattacharyya Violina [email protected] Aurora CO Feldman Amy [email protected] Denver CO Memon Zebunnissa [email protected] Buffalo NY

Ambartsumyan Lusine [email protected] Chestnut Hill MA Afzal Amna [email protected] Brookline MA Sevilla Wednesday [email protected] Pittsburgh PA

Joerger Shannon [email protected] St. Louis MO Godínez Hernández Brenda [email protected] Mexico D.F. Mexico Singh Namita [email protected] Seattle WA

Karjoo Sara [email protected] Philadelphia PA Bramlage Kristin [email protected] Cincinnati OH Shouval Dror [email protected] Brookline MA

Bitton Samuel [email protected] New Hyde Park NY Paul Adam [email protected] Balitmore MD Vortia Eugene [email protected] Shaker Heights OH

Carroll Matthew [email protected] Vancouver Canada Elkadri Abdul [email protected] Toronto Canada Carlin Eduardo [email protected] McKinney TX

Infantino Benjamin [email protected] Omaha NE

Group 10 Perez/Schwarz Group 11 Leichtner Group 12 Lee

Last Name First Name E‐Mail City State/Country Last Name First Name E‐Mail City State/Country Last Name First Name E‐Mail City State/Country

Bhardwaj Vrinda [email protected] Los Angeles CA Abell Rebecca [email protected] St. James NY Grzywacz Kelly [email protected] Montreal Canada

Kadzielski Sarah [email protected] Boston MA Kumar Soma [email protected] Columbus OH Rao Meenakshi [email protected] Jamaica Plain MA

Ruiz Navas Patricia [email protected] Medico D.F. Mexico Watson Sheree [email protected] Providence RI Barba Fabiola [email protected] Mexico

Muir Amanda [email protected] Philadelphia PA Lerner Diana [email protected] Milwuakee WI Sheflin‐Findling Shari [email protected] North Woodmere NY

Zacur George [email protected] Cincinnati FL Bayrer James [email protected] San Francisco CA Falaiye Tolulope [email protected] Nashville TN

Aggarwal Arun [email protected] Jackson Heights NY Bodicharla Rajasekha [email protected] Miami FL Ciciora Steven [email protected] Columbus OH

Uko Victor [email protected] Westlake OH Tran Khoa [email protected] Burlington MA Otu‐Nyarko Charles [email protected] River Ridge LA

Gurram Bhaskar [email protected] Milwuakee WI Bitar Anas [email protected] Oklahoma City OK

Group 13 Sood Group 14 Saavedra

Last Name First Name E‐Mail City State/Country Last Name First Name E‐Mail City State/Country

Woo Jennifer [email protected] Boston MA McElhanon Barbara [email protected] Atlanta GA

Valdes Estela [email protected] Guadalajara, Jalisco Mexico Aliaga Mabel [email protected] Mexico D.F. CP Mexico

Moya Diana [email protected] Buffalo NY Sampert Catherine [email protected] Salt Lake City UT

Kassabian Sirvart [email protected] Cleveland Heights OH Albenberg Lindsey [email protected] Philadelphia PA

Saginur Michael [email protected] Edmonton Canada Cameron Russell [email protected] Bronx NY

Middleton Jeremy [email protected] Atlanta GA Khalili Ali [email protected] Cleveland OH

Warolin Joshua [email protected] Nashville TN Wong Gregory [email protected] Houston TX

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How to Choose a Research

ProjectManu R. SoodDirector of Motility & Functional Bowel Disorders ProgramMedical College of Wisconsin, Milwaukee

Goals and Objectives

Goal: Enhance your understanding of what constitutes a good research project and how to go about finding one

Objectives: You should be able to…1. Identify the three critical components of a good

research project2. Know the appropriate steps to take in order to

find a good and successful project.

Why Do Research ?

Opportunity to answer questions

Expectation of the training program

Develop skills in critical thinking which are

always useful

Keys Points to Choosing a Research Project

People to help guide you

The research project is of personal interest

Find a defined “do able” project

The project should be worth doing

Balance your ideas and independence with those of others

Decide what area or field you want to focus on

Previous experience

Career goals

Mentor & support

PAST PERFORANCE IS A GOOD

PREDICTOR OF FUTURE SUCCESS

Watch out for the aggressive

salesperson

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Not Even Your Chief

Never let anyonepressure you intoa research project

What makes a good research project?

First and foremost, it must be interesting

You should learn something of value A technique, methodology, a way of

approaching problems, something you can take with you

It should be productive There should be a reasonable chance of

answering your question and publishing it

Fits your career goal

Pathways

Clinical Research Clinical trials Observational studies

Basic science

Population science

Translational science

Choosing a mentor

Remember:

One size does not

fit all1. Meet with possible

mentors, ask questions of others who have worked with them

2. Choose a mentor based on:

a. Past record, first and foremost

b. Potential projects, second

What to do in the first six months of your fellowship

1. Speak to potential research mentors

2. Identify possible projects (2-3 max)

3. Read about the topics and identify what you would enjoy and fits your career goal

4. Clearly define your goals

By the end of first year

After you have chosen a mentor, then…

Develop a research question Do a thorough search of medical literature Identify the edge of knowledge related to that

question and gaps in knowledge Be certain that your question has not already

been answered AND that filling the gaps is important

In other words, if you already knew the answer to your question, would anyone care?

Develop a testable hypothesis

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Study design

Relevant to Your Career Goals

Stay Focused

How will you be judged

Level of involvement Were you involved in developing the

concept, analyzing data, writing manuscript?

Were you just a data collector?

How productive was it? Did you produce an abstract, manuscript,

present at meetings, etc.

Extent of commitment to research

Do’s and Don’ts

Do:

Focus on the mentor

Articulate research question

Literature search

Stay focused, don’t stray

Make sure project is achievable

Don’t:

Choose a mentor just because you like them

Make assumptions

Study something in which your mentor does not have expertise.

Take on a project that is not well developed

Summary

Good research projects are interesting, educational, and productive

The fit with your career goals Identify a mentor first, then the project-

good mentors are invaluable Focus on developing a research question

and then identifying gaps in the knowledge

Be certain that someone will care if you are able to fill that knowledge gap

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The art and science of asking questions is the source of all knowledge

Thomas Berger

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Designing a Research Project

Joshua R. Friedman, M.D., Ph.D.Assistant Professor of Pediatrics

The Children’s Hospital of PhiladelphiaThe University of Pennsylvania School of Medicine

Overview

• General Research Question

• Hypothesis

• Specific Research Questions

• Study Strategy

Research types

Clinical ResearchClinical

ResearchBasic

ResearchBasic

ResearchTranslational

ResearchTranslational

Research

What Makes a Successful Research What Makes a Successful Research 

Project?Project?

FINER

• Feasible

• Interesting

• Novel

• Ethical

• Relevant

http://www.fmdrl.org/group/index.cfm?event=c.showWikiPage&pageId=473

Feasible

• Is the question answerable?

• Do you have access to all the the materials needed for the study?

• Will you have enough time and money?

• Do you or your mentor have the expertise to complete the study?

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Interesting

• Are you interested in the study?

• Will others be interested in your results?

Novel

• Has the study been done before?

• Will the study add new information?

Ethical

• Can the study be done in a way that does not subject subjects to excess risks?

Relevant

• Will it further medical science?

• Will the results change clinical practice, health policy, or direct new avenues of research?

Overview

• General Research Question

• Hypothesis

• Specific Research Questions

• Study Strategy

General Research QuestionGeneral Research Question

HypothesisHypothesis

Specific Research Questions

Specific Research Questions

Study StrategyStudy Strategy

Research Topic

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General Research Question

• Derives from the research topic

• Broadly encompassing question

• Allows you to generate a hypothesis

General Research Question Development

• Literature Review

– Identify related research

– Define gaps in current knowledge base

– Avoid redundancy

– Set your research within the proper context

Tip

At the start of your research project, identify “model” articles…use these as guides in the design of your research project.

General Research Question Development

• Discuss with Mentor and Other Experts

– Unpublished work

– Recent discussion at meetings

– “Common” knowledge

– General & specialty interest in the field

General Research Question

• Be prepared to justify with published evidence to support

– Why is it a good idea?

– Why is the research worth doing?

• Consider the consequences if the research is positive, negative, or inconclusive

• Will others be interested in this work?

General Research Question

• Expresses curiosity about the relationship between two (or more) phenomena

• Describes a population under study

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General Research Question

Does drinking coffee improve the procedural skills of pediatric gastroenterology fellows?

General Research Question

HypothesisHypothesis

Specific Research Questions

Specific Research Questions

Study StrategyStudy Strategy

Research Topic

Formulating a Hypothesis

• Formulation of the hypothesis comes after you have had the idea for the research, performed a careful and thorough literature review, and generated a general research question

• Puts the research into focus

• Leads directly to study design

What is a Hypothesis?

• A statement derived from the general research question that is used as a basis for argument

• A statement that can be tested

• Essential part of statistical inference

Formulating a Hypothesis

• Use prior evidence

– Clinical observation

– Published literature

– Basic biomedical (mechanistic) understanding

– Preliminary research data

Formulating a Hypothesis

• Good hypotheses

– Make a prediction

– Specify independent and dependent variables

– Specify effects of independent variables on dependent variables

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Formulating a Hypothesis

• Consists of two competing claims:

– Null hypothesis (H0) ‐ negation of the research question of interest

– Alternative hypothesis (H1) ‐ acceptance of the research question of interest

Null Hypothesis

• Important in statistical testing – receives special consideration

• Must be disproved statistically

• Cannot be rejected unless the evidence against it is sufficiently strong

• Reject H0 in favor of H1 or Do not reject H0

• Never Reject H1 or Accept H1

Hypotheses

Good hypotheses

– Specific

– In advance

– Simple

– Null is stated

Bad hypotheses

– Vague

– After the fact

– Complex

– No clear null

Tip

Look down the road; don’t formulate a hypothesis that will lead to a type of research you cannot or do not want to perform.

Hypothesis

Does drinking coffee improve the procedural skills of pediatric gastroenterology fellows?

The amount of coffee consumed prior to performing endoscopy by pediatric GI fellows increases the rate of success of the procedure.

Null Hypothesis

The amount of coffee consumed prior to performing endoscopy by pediatric GI fellows does not increase the rate of success of the procedure.

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Example

Does drinking coffee improve pediatric GI fellows’ ability to perform endoscopic procedures?

Can beer be considered a clear liquid during a colon preparation?

General Research Question

Hypothesis

Specific Research Questions

Specific Research Questions

Study StrategyStudy Strategy

Research Topic

Specific Research Questions

• What are the specific research questions that need to be answered in order to support or reject the null hypothesis

• Can be answered with: Yes, No, or by a Figure

• Sufficient detail to make the study strategy and analysis obvious

• No more than 3 questions

Specific Research Questions

The amount of coffee consumed prior to performing endoscopy by pediatric GI fellows does not correlate with the rate of success of the procedure.

1.  Does the volume of coffee consumed affect the success rate of EGD or colonoscopy?

2. Does the length of time the coffee was consumed prior to the proceed have an effect on the rate of success?

General Research Question

Hypothesis

Specific Research Questions

Study StrategyStudy Strategy

Research Topic Study Strategy

• Specific Research Questions should lead to the study strategy

– observational study vs. interventional Study

• How can the questions be answered?

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Study Strategy

• Define: Subjects, Interventions, Controls, Outcomes of Relevance

• How can the questions be answered?

Measurement

• Moves the hypothesis from concepts to concrete data

• Define or assign numbers to the concepts under study

• Organizes data collection

Measurement

• Coffee consumption ‐‐ ounces of coffee

• Success rate ‐‐ time of procedure in minues, intubation of the terminal ileum

Study Strategy – Statistics

• Consult with a statistician‐ at the outset of the study design process

• Discuss study design

• Types of statistical tests

• Power of study

• Sample size

Study Strategy

• Is the strategy feasible?– Time

– Money

– People

– Equipment

– Patient population– Animal resources

• Consider alternative strategies– List advantages and disadvantages

Study Strategy ‐ Ethics

• Don’t leave ethical considerations as a last step item

• Protection of Participants

• Informed Consent

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Study Strategy – Formalized Protocol

• Written study plan, detailed

• Without a protocol research can become an unguided exercise in data collection

• Necessary for a study to be replicable

Formalized Protocol

• Background and Rationale

• Hypothesis

• Objectives ‐ Specific Research Questions

• Research Design

• Study Flowsheet/Timeline

• Methods

– Patient Population

– Enrollment criteria

– Recruitment Plan

– Sample Size

– Intervention

– Outcome measurements

– Data Analysis & Statistics

• Human Subjects Protections Consent Procedures

Tip

Have your statistician review the final protocol!

Research Study Design

• Iterative process

• Re‐examination at each step of the process

• May need to back track and rework

• May need to abandon project

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RESEARCH ETHICSDESIGNING AN ETHICAL STUDY

Daniel S. Kamin MDChildren’s Hospital Boston

Division of Gastroenterology and Nutrition

Objectives

• Key Historical Documents• Underlying Ethical Principles• Difference between clinical care and

research• Difference between children and

adults• Heuristic for determining ethical

adequacy of a research study

The Pediatric Dilemma

‘We want children to benefit from the dramatic and accelerating rate of progress in medical care that is fueled by scientific research. At the same time, we do not want to place any children at risk of being harmed by participating in such research, even though their very involvement may be essential to improving the overall medical care of children’

Richard Behrman, IOM 2004

Key Documents in Research Ethics

• Nuremberg Code (1949)– informed consent in research

• WHO Declaration of Helsinki (1964)– pediatric research and direct benefit

• Belmont Report (1978)– US gov’t effort to codify the ethical conduct of research

• Subpart D of 45 CFR Part 46 (1983)– US gov’t specific regulations for pediatric research

• IOM review of Subpart D (2004)– clarify meaning of key concepts and optimal procedures for recruitment in pediatric research

Adequate Balance in Pediatrics--Given Limited Autonomy

Special attention to beneficence and justice is necessary because:• autonomy is compromised (at least legally, often ethically)• parents give permission, but this is not the same as consent  

Belmont Report:Autonomy

• Greek autos (‘self’) nomos (‘rule’)

• Respect for Autonomy promotes self-rule that is free from controlling interference by others and from certain limitations such as inadequate understanding that limits meaningful choice

• Fundamental tenet: extensive informed consent procedures, independent research subject advocates

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Consent• The ethical and legal requirements of

consent have two aspects:

Provision of information: Purpose

Methods Demands Risks, inconveniences, discomforts

Possible outcomes of the research, and implications

Exercise of a voluntary choice to participate.

Belmont Report:Beneficence

• Hierarchy of obligation: 1. prevent harm

2. remove harm

3. promote our patient’s or patients’ welfare

• Pediatricians are familiar with the duty to promote the welfare of our patients, sometimes in spite of parents’ wishes

• Children are ‘vulnerable’: necessity for special protections as research subjects

Belmont Report:Justice

• Most complex and philosophically rich concept

• Justice ≅ Fairness

• Fairness achieved when equals are treated equally, and unequals are treated unequally

• Problem: how do we gauge equality, and who does the gauging?

• A nice gloss: Research methods should not favor or disfavor people on the basis of gender, race, class, socioeconomics, religion, sexual orientation, unless that characteristic is a fundamental variable in an otherwise scientifically and ethically valid investigation

Autonomy vs Beneficence in Research

28/68 (41%)  parents let physician decide if child should participate

% of paren

ts

1. Challenge to achieve pure autonomy 2. Trust in physicians important to parents3. Even greater burden on physicians/scientists/IRBs to protect 

a child/children/community from unexpected but unreasonablypredictable harm

Many parents not understand basic elements of the consent

Based on these principles, there are ‘rules’ that guide researchers to construct ethically permissible scientific investigations

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Clinical care or research?

• Sometimes activity is easily classifiable, sometimes it is not

• Belmont Report– Research: ‘an activity designed to test a

hypothesis, permit conclusions to be drawn, and thereby develop or contribute to generalizable knowledge’

– Practice: ‘interventions that are designed solely to enhance the well-being of an individual patient that have a reasonable expectation of success’

Clinical care or research?

• Why Does it Matter?

• When we do research, we have a conflict of interest– Do what is good for the study– Do what is good for the patient

• Rules and oversight (IRBs) to help prevent the conflict from causing harm, and eroding trust in the system

Children versus Adults

• Adults: risks in proportion to benefits and to the value of the generalizable knowledge: no absolutes and not necessarily about subjects’ own conditions

• Children: protection from more than minimal risk– absolute risk categories(i) expectation of direct benefit to subjects; or

(ii) advancing the general knowledge about subjects’ condition

More than minimal risk

• Children participate after (i) adequate assent/permission, but, if (ii) risk more than ‘minimal’– harms must be balanced by prospect for

direct benefit to subjects; or,

– harms must represent only minor increase over minimal risk AND the research ought to yield vital knowledge about subjects’condition

Pediatric Risk CategoriesPediatric Risk Categories

Prospect of direct benefit

No prospect of direct benefit

Commensurate experiences

Vital knowledge re: subjects’ disorder

Risk/benefit is as favorable as alternatives

Risk is justified by the benefits

Minimal riskMinor increase over minimal risk

Greater than minor increase over minimal risk

Risk is justified by the benefits

Risk/benefit is as favorable as alternatives

Risk is not justifiedby the benefits

Not ethically and/orlegally justifiable

Categories refer to sections in Subpart D of 45 CFR 46

Ethical Adequacy in Pediatric Research-A Method

• Each of the Belmont Principles maps (more or less) to particular rules and regulations

• Consider each principle a ‘prism’ through which a protocol must pass

• Beneficence–harms and benefits• Autonomy– considerations for adequate

assent/permissions, avoidance of coercion• Justice–fair access or avoidance of

overrepresentation (intended or unintended)

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The ModelBeneficence

Respect for Autonomy

Justice

Harms‐ Minimal risk‐Minor increase‐More than minor increaseBenefits‐ Direct benefit ‐ Knowledge about subject condition

Assent‐Developmental sensitivity‐ Attest to respect for developing

autonomy

Permission‐ Parents know what is 

best for own children‐ Legal and moral responsibility 

Benefits and burdens of research ought to be shared fairly

Prism One - Beneficence

• Minimal Risk Level– Harms/discomforts in proposed research

equivalent to harms/discomforts encountered by healthy children in their daily lives or experienced in routine physical or psychological examinations

– Relate to maturity level of research subjects– Consider duration, magnitude and probabilities

when determining level of risk• Minor Increase over Minimal Risk Level

– Slightly above minimal risk– Standard child is still a healthy child

Examples of Risk Categories

Procedure Risk Category

Minimal Risk Minor Increase More than Minor

Single Venipuncture

X

Chest XR X

DEXA X

LP X

Liver biopsy X

OGTT X

Skin biopsy X

Urine catheterization

X

Source NHRPAC, 2002

Prism One- risk evaluation

• Additional Considerations– Observational versus interventional

studies

– RDBPCT versus comparison to standard of care

– Relatively healthy, chronically, or catastrophically ill subjects

– DSMBs

Prism Two- Respect for Autonomy

• Assent/permission is a process, not a form

• Clarify for children degree of control they will have over participation decision

• Whenever possible, obtaining assent with– No prospect for direct benefit– more important to

have assent and willingness to participate

– Prospect for direct benefit– still important to discuss, even when children do not want to participate

• Need for repeated assent when children reach new developmental milestones over time

Prism Two- Payments

• Agreement to participate in research should not be coerced: unduly influenced by psychological, financial, or other pressures

• Compensation ought to be discussed openly, but not emphasized during the permission/assent process in manner that unduly influences decision-making

• Compensation is good when– Communicates appreciation– Encourages participation for people that would want

to participate but for (financial) hardships assuaged by the compensation

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Prism Three- Justice

• Consider whether a study encourages under- or overrepresentation on the basis of social categories that are not the subject of the study

• If one is selecting patients based on a vulnerable social category, is this for a medically and scientifically important reason?

• Are there study recruitment methods or compensation strategies that can assuage unwanted under- or overrepresenation?

• International Research- beneficence and justice in action

Summary

• Twenty minute overview of research ethics is not easy

• As a vulnerable group, children garner special protections from harm and assurances of benefit

• Unique to pediatric research is the determinative nature of risk level and subject-focused benefit – nothing more than minimal risk unless particular

pediatric subjects will benefit directly or indirectly

References• Field MJ, Berman RE. Children CoCRI. The Ethical Conduct of Clinical

Research Involving Children. Washington, DC: Institute of Medicine;2004.

• Flotte et al: Recent Developments in the Protection of Pediatric Research Subjects. J Pediatr 2006;149:285-6

• Wilfond, B. Ethical Issues in Pediatric Research: Placebo controlled trials for gastroesophageal reflux. 2002. http://www.fda.gov/ohrms/dockets/ac/02/slides/3870S1_04_Wilfond/

• ‘Special Protections for Children as Research Subjects’, The Office for Human Research Protections, Department of Health and Human Servicers, accessed December 10th, 2010. http://www.hhs.gov/ohrp/children/

• Kopelman, L. ‘Children as Research Subjects: Moral disputes, regulatory guidance, and recent court decisions’. The Mount Sinai Journal of Medicine. 2006. 73: 596-604.

• Ramsey B. Appropriate Compensation of Pediatric Research Participants: Thoughts From an Institute for Medicine Committee. J Peds 2006 149:S15-S9

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1© 2010 Childtren’s Memorial Hospital

Writing and Presenting Abstract for a Writing and Presenting Abstract for a National meetingNational meeting

““Begin with the End in MindBegin with the End in Mind””

Valeria Cohran M.D., M.S,Medical Director of Intestinal Rehabilitation/TransplantChildren’s Memorial Hospital

2© 2010 Childtren’s Memorial Hospital

OUTLINE:OUTLINE:

•• Writing an abstractWriting an abstract

•• (tips and tricks)(tips and tricks)

•• Presenting an Presenting an abstractabstract

3© 2010 Childtren’s Memorial Hospital

LetLet’’s start writing an Abstract!s start writing an Abstract!

Know the rulesKnow the rules–– Can Can notnot be previously presented at another meetingbe previously presented at another meeting–– Can Can notnot be published at time of presentationbe published at time of presentation

Know the deadlinesKnow the deadlines–– Often 5 Often 5 –– 6 months in advance of the meeting6 months in advance of the meeting–– Example: DDW (May) deadline: early DecemberExample: DDW (May) deadline: early December

NASPGHN (Oct) deadline: MayNASPGHN (Oct) deadline: MayAASLD (Oct) deadline: May AASLD (Oct) deadline: May

Know the styleKnow the style–– Read the abstracts from the previous meetingsRead the abstracts from the previous meetings–– Pay attention to font size, formatting, and lengthPay attention to font size, formatting, and length

4© 2010 Childtren’s Memorial Hospital

Style: clear and strongStyle: clear and strong!!

You want your abstract to be hardYou want your abstract to be hard--hitting!hitting!––11stst person, active voice:person, active voice:

““We studiedWe studied…”…” ““We observedWe observed…”…”

not not …… ““It was observed thatIt was observed that…”…”

Avoid abbreviations (no more than 2)Avoid abbreviations (no more than 2)

One idea One idea one abstractone abstract

Remember: Good science requires good Remember: Good science requires good writingwriting!!

5© 2010 Childtren’s Memorial Hospital

Abstract : FormatAbstract : Format(always 7 parts)(always 7 parts)

TitleTitleAuthors / InstitutionAuthors / Institution Introduction / BackgroundIntroduction / BackgroundHypothesis / AimHypothesis / AimMethodsMethodsResultsResultsConclusionConclusion

6© 2010 Childtren’s Memorial Hospital

1. Title1. Title

““An accurate promise of the abstractAn accurate promise of the abstract’’s s contentscontents”” D. J. PiersonD. J. Pierson

Most effective when it refers to its overall Most effective when it refers to its overall ““take home messagetake home message”” Ideally: 10 Ideally: 10 –– 12 words12 words

––Easy to understandEasy to understand––No abbreviationsNo abbreviations

Avoid Avoid ““cutecute”” jokes and plays on wordsjokes and plays on words..

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7© 2010 Childtren’s Memorial Hospital

Limited to the people who actually designed, did, and analyzed the study.Rank order of the relative contributions

1st author (presenter, you!) last author (mentor)Conflict of Interest

2. Authors & Institution2. Authors & Institution

8© 2010 Childtren’s Memorial Hospital

3. Introduction/Background3. Introduction/Background

Answers the question:Answers the question:““Why did you start?Why did you start?””

Provides context for why you Provides context for why you performed the studyperformed the studyAssume readers/reviewers have some Assume readers/reviewers have some

familiarity with subjectfamiliarity with subject Ideally: 1 Ideally: 1 –– 2 sentences2 sentences

9© 2010 Childtren’s Memorial Hospital

4. Hypothesis/Purpose4. Hypothesis/Purpose

Answers the question:Answers the question:

““What was your goal?What was your goal?””

One definitive sentence!One definitive sentence!

Acceptable formats:Acceptable formats:

““We hypothesizedWe hypothesized…”…”

““The aim of this study was The aim of this study was …”…”

““The goal of this studyThe goal of this study……..””

Surprisingly, often omitted!Surprisingly, often omitted!

10© 2010 Childtren’s Memorial Hospital

5. Methods5. Methods

Answers the question:Answers the question:

““What did you do?What did you do?””

Can be written before study startedCan be written before study started

This section most often cited by reviewers as reason This section most often cited by reviewers as reason for a rejection!for a rejection!

Concise Concise –– details may be omitteddetails may be omitted

Basic researchBasic research: models, techniques: models, techniquesClinical researchClinical research: subject pop. (N=): subject pop. (N=)retroretro-- or prospective, randomization, controlledor prospective, randomization, controlledStatistical analysis of dataStatistical analysis of data

11© 2010 Childtren’s Memorial Hospital

6. Results6. Results

Answers the question:

“What did you find?”

The phrase “The findings will be presented” is unacceptable!

Need to include real data– * N= and p= values a good idea.

Something is either significant or it is not! – Do not use phrases “trending towards”, “almost

significant”, “different, but not statistically significant”

A table or figure is ok – make sure it:– is not too small– does not duplicate text

12© 2010 Childtren’s Memorial Hospital

7. Conclusion7. Conclusion

Concise statement of why the study’s findings are important

Reasonable and supported by the results

Can include interpretation

Do not:– make more of the data than is deserved– restate results

Optional: If space allows…can include implication statement and/or future direction

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13© 2010 Childtren’s Memorial Hospital

References:References:

Boice, R. The new Faculty Member. 1992; Jossey-Bass Publishers, San Francisco.

McCabe, LL; McCabe, ERB. How to succeed in academics. Academic Press, Elsevier 2000.

Pierson, DJ. How to write an abstract that will be accepted for presentation at a national meeting. RespCare 49:1206-1212; 2004.

Cole, FL. Writing a research abstract. J Emerg Nurs23:487-90; 1997.

Lister, G. Mentorship: Lessons I wish I learned the first time. Curr Opinion in Pediatrics 16:579-584; 2004.

14© 2010 Childtren’s Memorial Hospital

Art of Oral PresentationArt of Oral Presentation

15© 2010 Childtren’s Memorial Hospital

4 W4 W’’s in Presentings in Presenting

Who?

What?

Where?

When?

16© 2010 Childtren’s Memorial Hospital

4 W4 W’’s in Presentings in Presenting

Who?–Know your audience

• Scientists, medical or graduate students, nurses, physicians

–Adult Learning Behaviors• Motivated to learn• Aims must be clear• Audience participation

17© 2010 Childtren’s Memorial Hospital

4 W4 W’’s in Presentings in Presenting

What?

–Research• Hypothesis• Significance/Aims• Methods• Results• Conclusions

18© 2010 Childtren’s Memorial Hospital

4 W4 W’’s in Presentings in Presenting

Where?

–National scientific meeting

–Departmental meeting

–Fellows’ conference

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19© 2010 Childtren’s Memorial Hospital

4 W4 W’’s in Presentings in Presenting

When?When?

–In the morning–After lunch–During a dinner/lunch session

• Entertaining slide/cartoon• Carefully worded joke

20© 2010 Childtren’s Memorial Hospital

Research Presentations

Research

–Hypothesis–Significance/Aims–Methods–Results–Conclusions

21© 2010 Childtren’s Memorial Hospital

Balistreri, W JPGN vol 35(1):1-4.22© 2010 Childtren’s Memorial Hospital

Principles of PresentingPrinciples of Presenting

Keep it Large and Legible (KILL)Back of the room should be able to read your

slides–6-8 lines of information

Audience reads 500 words/ minuteSpoken word 125 words/minuteSlides

– Consistent – Not Distracting

23© 2010 Childtren’s Memorial Hospital

Principles of PresentingPrinciples of Presenting

KILL means to Keep it Large and Legible

Please keep the text on your slide to the largest font possible so that the people in the back of the

room are able to read your slides.

Please remember that the audience can read faster than you can speak (500 words/min) as

compared to the spoken word (125 words/minute).

Please try to keep your slide back grounds consistent. Also remember it is important that you

choose a background that is non-distracting.

24© 2010 Childtren’s Memorial Hospital

Principles of PresentingPrinciples of Presenting

Keep it Large and Legible (KILL)Back of the room should be able to read your

slides–6-8 lines of information

Audience reads 500 words/ minuteSpoken word 125 words/minuteSlides

– Consistent – Not Distracting

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25© 2010 Childtren’s Memorial Hospital

PresentationsPresentations

Font (TNR)

Font (TNR bold)

Font (Arial)

Font (Arial bold)Font (Arial Black bold)

Is the Font size the same?Can it be read in the back of the room? 26© 2010 Childtren’s Memorial Hospital

TextText

Concise

Clear

Proofread and Spell-check

Audience reads faster than you speak!

27© 2010 Childtren’s Memorial Hospital

Principles of PresentingPrinciples of Presenting

Slides

–Title each slide–Carefully chosen animation–Pointer use–Explain your graphs/figures–Transition between slides

28© 2010 Childtren’s Memorial Hospital

0

200

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1200

Intestine + Liver Intestine only

Number of UNOS listing for Number of UNOS listing for ITxITx Oct 1987Oct 1987--Jan Jan 20052005

74.3% vs 25.7%

1159

400

29© 2010 Childtren’s Memorial Hospital

16.9

83.1

46.4

53.6

0

10

20

30

40

50

60

70

80

90

100

%LIL

LIO

<17 yrs, n=1106 >18 yrs, n=453

Differences in Liver Listing Status between Pediatric Differences in Liver Listing Status between Pediatric and Adult Intestinal Transplantand Adult Intestinal Transplant

30© 2010 Childtren’s Memorial Hospital

Waiting List Mortality

light blue = intestine only dark blue= combined liver/intestine

Chungfat et al, Journal of Am Coll Surgery 2007;205:755-761

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31© 2010 Childtren’s Memorial Hospital

PresentationPresentation

Bold TextFiguresAnimationTransitions between slidesPractice

32© 2010 Childtren’s Memorial Hospital

ConclusionsConclusions

4 W’s of Presenting– Who, What, When, Why

KILL– Keep it Large and Legible

Slides– Must be consistent, – Proof-read, – Transitions

Practice

33© 2010 Childtren’s Memorial Hospital

AcknowledgmentsAcknowledgments

Drew Drew FeranchakFeranchak, M.D., M.D.NestleNASPGHAN

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Breakfast with NASPGHAN and Breakfast with NASPGHAN and CDHNFCDHNF

Kathleen Schwarz, MD Kathleen Schwarz, MD & &

Maria E. Perez, DOMaria E. Perez, DO

North American Society for Pediatric North American Society for Pediatric Gastroenterology, Gastroenterology, HepatologyHepatology, and Nutrition, and Nutrition

•• Only society in North America and the Only society in North America and the largest in the world serving the Pediatric largest in the world serving the Pediatric Gastroenterology and Nutrition Gastroenterology and Nutrition communitiescommunities

•• More than 1400 pediatric More than 1400 pediatric gastroenterologists in North Americagastroenterologists in North America

NASPGHAN MissionNASPGHAN Mission

•• Advance understanding of normal development, Advance understanding of normal development, physiology, and physiology, and pathophysiologypathophysiology of diseases of of diseases of the GI tract and liver in childrenthe GI tract and liver in children

•• Improve quality of care by fostering the Improve quality of care by fostering the dissemination of this knowledge through dissemination of this knowledge through scientific meetingsscientific meetings

•• Professional and public educationProfessional and public education•• Policy developmentPolicy development•• Serve as effective voices for members and the Serve as effective voices for members and the

professionprofession

Benefits of MembershipBenefits of Membership

•• Free participation at Free participation at yearly Fellows yearly Fellows ConferencesConferences

•• Reduced registration fees Reduced registration fees for the NASPGHAN for the NASPGHAN Annual Meeting, Annual Meeting, Postgraduate course, and Postgraduate course, and other educational other educational offeringsofferings

•• Reduced subscription Reduced subscription rates for rates for JPGNJPGN

•• Free NASPGHAN Free NASPGHAN Quarterly NewsletterQuarterly Newsletter

•• Free subscription to the Free subscription to the PedsGIPedsGI and and PedsGIFellowsPedsGIFellowsBulletin BoardBulletin Board

•• Access to the MembersAccess to the Members--Only section of the Only section of the NASPGHAN websiteNASPGHAN website

•• Eligibility for research Eligibility for research awards and to apply for awards and to apply for research grants from research grants from CDHNFCDHNF

•• Opportunity to become a Opportunity to become a member of and participate member of and participate in NASPGHAN Committeesin NASPGHAN Committees

NASPGHAN CommitteesNASPGHAN Committees

•• Public Affairs & AdvocacyPublic Affairs & Advocacy•• Awards Awards •• Clinical Care & QualityClinical Care & Quality•• EndoscopyEndoscopy & Procedures& Procedures•• EthicsEthics•• FellowsFellows•• FinanceFinance•• HepatologyHepatology•• IBDIBD•• InternationalInternational•• MOC Task ForceMOC Task Force•• NeurogastroenterologyNeurogastroenterology & &

MotilityMotility

•• Nominations *Nominations *•• NutritionNutrition•• Obesity Task Force Obesity Task Force •• PractitionerPractitioner’’s Task Forces Task Force•• Professional DevelopmentProfessional Development•• Professional EducationProfessional Education•• Public EducationPublic Education•• PublicationsPublications•• ResearchResearch•• Technology *Technology *•• TrainingTraining

Committee Selection ProcessCommittee Selection Process

•• SignSign--up sheets at 1up sheets at 1stst Year Fellows ConferenceYear Fellows Conference•• Sign up for 2 committeesSign up for 2 committees•• Random selection process Random selection process –– two 1two 1stst year fellows year fellows

per committeeper committee•• Those not chosen for a committee, will be given Those not chosen for a committee, will be given

the opportunity to join the Fellows Committeethe opportunity to join the Fellows Committee•• Committee meetings held at DDW and Committee meetings held at DDW and

NASPGHAN annual meetingsNASPGHAN annual meetings

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NASPGHAN Fellows CommitteeNASPGHAN Fellows Committee

•• Open to Open to allall FellowsFellows•• Educate new fellows about NASPGHANEducate new fellows about NASPGHAN•• Annual reminder regarding the ITEAnnual reminder regarding the ITE•• Fellows receptions at both DDW and NASPGHANFellows receptions at both DDW and NASPGHAN•• Responsible for committee selection processResponsible for committee selection process•• Education about the individual Fellows Education about the individual Fellows

ConferencesConferences•• Maintenance of the Fellows section on the Maintenance of the Fellows section on the

NASPGHAN websiteNASPGHAN website

NASPGHAN Fellows CommitteeNASPGHAN Fellows Committee

•• BOARD REVIEWBOARD REVIEW–– Main focus of Fellows Committee over the past Main focus of Fellows Committee over the past

two yearstwo years–– Monthly board review questions via Monthly board review questions via ListServListServ–– Board Review BookBoard Review Book

•• Approx 90 fellows (past and current)Approx 90 fellows (past and current)•• Senior Editor Senior Editor –– Judith Judith SondheimerSondheimer (Georgetown)(Georgetown)•• 13 section editors13 section editors•• Will be published book, available to all Will be published book, available to all

NASPGHAN membersNASPGHAN members•• Funding by NestleFunding by Nestle•• Publisher Publisher –– Castle Connolly Graduate Medical Castle Connolly Graduate Medical

PublishingPublishing

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Getting the Most Out of Your Getting the Most Out of Your FellowshipFellowship

Vicky Lee Ng, MD, FRCPC

Division of Pediatric GI/Hepatology and Nutrition

SickKids Transplant Centre

The Hospital for Sick Children

University of Toronto

January 2011

How can you get the most out of your fellowship?

Goals of Fellowship TrainingGoals of Fellowship Training

• Clinically competent in all aspects of general pediatric GI (identify 1‐2 areas of clinical expertise)

• Learn about research

• Find a job

• Define and start building a career

Goals of Fellowship TrainingGoals of Fellowship Training

• Begin to build skill sets and contacts necessary to:– Become a physician‐scientist– Become a clinician educator– Become a clinical expert– Run your own practice– Become a division director/department chair/fellowship director

– Work in industry

Requirements for Board CertificationRequirements for Board Certification

•• Clinical competenceClinical competence

•• Comprehensive core curriculum of scholarly Comprehensive core curriculum of scholarly activitiesactivities

•• Areas of scholarly activity:Areas of scholarly activity:–– Basic, Clinical, Translational researchBasic, Clinical, Translational research–– Health services researchHealth services research–– Quality improvementQuality improvement

–– Bioethics Bioethics –– EducationEducation

–– Public policyPublic policy

Clinical CompetenceClinical Competence

• Throw yourself into your clinical experiences

• See as many patients as you can during your clinical time

• Take every opportunity to do ANY procedure, especially those you’re least comfortable with

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Clinical CompetenceClinical Competence

• Pay attention to how different people handle similar problems (fussy baby, adolescent with abdominal pain, asymptomatic elevated LFTs)

• Take advantage of “external knowledge” –nurses, nurse practitioners, coordinators, nutritionists, etc.

• Ask lots of questions

Clinical CompetenceClinical Competence• Observe procedures (ERCP, Kasai, IBD surgery, manometry)

• Get as much Pathology and Radiology experience as you can

• Listen to the senior staff talk about the cases that puzzle/interest them

• Read about your patients occasionally– Peer‐reviewed research articles– Review articles– Textbooks

– Google (Scholar)

Choosing an Area of Scholarly ActivityChoosing an Area of Scholarly Activity Choosing a Research ProjectChoosing a Research Project

• Take note/Awareness of basic reactions:

– What kind of questions grab your attention?

– At a conference – what kinds of talks excite you/put you to sleep?

– What kind of papers do you enjoy reading?

Choosing a Research Project, Paul Doughty

Choosing a Research ProjectChoosing a Research Project

•• What do you like to do?What do you like to do?

–– Imagine what youImagine what you’’ll be doing dayll be doing day‐‐toto‐‐day to day to get your dataget your data

Choosing a Research Project, Paul Doughty

How To Choose a Good ProjectHow To Choose a Good Project

• Be informed!! (or hang around people who are)

• Look for gaps in the current knowledge:

–Data are too difficult for more senior people to bother getting

–Lack of the right technique

–Nobody’s gotten around to it yet

Choosing a Research Project, Paul Doughty

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•• Follow Follow ““hothot”” journals journals –– ee‐‐mail Table of mail Table of ContentsContents

•• Talk to smart people Talk to smart people –– senior staff in your senior staff in your division, people you meet at conferencesdivision, people you meet at conferences

•• Pay attention to cool weird stuff that happens Pay attention to cool weird stuff that happens –– Why??Why??

How To Choose a Good ProjectHow To Choose a Good Project Choosing a MentorChoosing a Mentor

Coming Up!

It’s time to get a REAL job

NASPGHANPeds GI Workforce Survey 2003‐04

USA Canada TotalEmployment Status

University/Academic 56% 87% 58%

Private Practice 23% 5% 22%Hospital or Clinic 16% 8% 16%Pharm or formula company

1% 0 1%

HMO 2% 0 2%Academic Appt

Yes 83% 97% 84%

No 17% 3% 16%Percent who receive a portion of salary from grants

24% 11%

NASPGHANPeds GI Workforce Survey 2003‐04

USA Canada TotalAcademic Track

Adjunct 7% 12% 7%

Clinical 61% 55% 61%Tenure 32% 33% 32%

Proportion Effort

Outpatient GI Clinic 38% 26% 37%

Procedures 13% 9% 13%Inpatient Rounds 15% 18% 15%Research 12% 19% 13%Teaching 5% 7% 5%Admin 7% 10% 7%

Career DevelopmentCareer DevelopmentFinding a jobFinding a job

• Use national meetings as a chance to meet people

• Ask your mentor(s) to introduce you to more senior people

• Use contacts (former fellows, other 1st year fellows) to learn about opportunities

• Become involved in NASPGHAN (bulletin board, website, JPGN, committees)

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Career DevelopmentCareer Development

• Take time to think about your life/career

• Write down what you want

• Try to find someone to pattern yourself after

• Identify at least one senior person who will talk to you about your career, not just your research

• Share what you’re thinking ‐ people WANT to help you!

Career DevelopmentCareer DevelopmentBasic SkillsBasic Skills

• Learn to manage your time

–Handle paper only once–Do dictations immediately

• Read, Read, Read–Organize and file articles–“Chance favors the prepared mind”

• Write as you go• Sharpen the saw

In the endIn the end……....

• Don’t panic about the future• Take advantage of the expertise that surrounds you

• Be indulgent – choose things that REALLY interest you

• Push yourself• Enjoy the journey

ResourcesResources

• http://sciencecareers.sciencemag.org/career_development

• http://www.acphysci.com/aps/app

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Choosing a MentorChoosing a Mentor

NASPGHAN Fellows ConferenceNASPGHAN Fellows Conference

January 15, 2011January 15, 2011

Peter Lee, MDPeter Lee, MD

INOVA Pediatric Digestive Disease CenterINOVA Pediatric Digestive Disease Center

What is a Mentor ?What is a Mentor ?

What is a Mentor ?What is a Mentor ?

A wise and trusted counselor or teacherA wise and trusted counselor or teacher

Today, Today, mentorshipmentorship refers to a refers to a developmental relationship in which a developmental relationship in which a more experienced person helps a less more experienced person helps a less experienced individuals to developexperienced individuals to develop………… in in a spectrum of capacities.a spectrum of capacities.

Why do I need a Mentor ?Why do I need a Mentor ?

January is National Mentoring MonthJanuary is National Mentoring Month

I think mentors are important and I don't think anybody makes it in the world without some form of mentorship. Nobody makes it alone. Nobody has made it alone. And we are all mentors to people even when we don't know it.

Oprah Winfrey

WhoMentoredYou.org

Qualities of a MentorQualities of a Mentor

Knowledgeable, respected, supportive, Knowledgeable, respected, supportive, honest, enthusiastic, encouraginghonest, enthusiastic, encouraging

““Academic ParentAcademic Parent””

A good Mentor A good Mentor teaches, promotes, teaches, promotes, supports and advocates supports and advocates for their Menteefor their Mentee

A good Mentor is A good Mentor is invested invested in their Menteein their Mentee

Qualities of a MentorQualities of a Mentor

A good Mentor A good Mentor teaches:teaches:

Writing skills Writing skills –– abstract submission, grant abstract submission, grant writingwriting

Oral presentation skillsOral presentation skills

Critical ThinkingCritical Thinking

Time managementTime management

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Qualities of a MentorQualities of a Mentor

A good Mentor A good Mentor promotes:promotes:

Is honest with you Is honest with you –– Strengths and WeaknessesStrengths and Weaknesses

Guides you and provides constructive criticismGuides you and provides constructive criticism

Encourages you to strive for excellenceEncourages you to strive for excellence

Qualities of a MentorQualities of a Mentor

A good Mentor A good Mentor supports:supports:

Makes time for youMakes time for you

Listens wellListens well

Inspires you (role model)Inspires you (role model)

Dealing with disappointmentDealing with disappointment

Qualities of a MentorQualities of a Mentor

A good Mentor A good Mentor advocates:advocates:

Career Planning and DevelopmentCareer Planning and Development

Provides opportunities Provides opportunities

NetworkingNetworking

How do I find one?How do I find one?

Mentor Tree

It may take more than one apple to fill all those needs

How do I Start?How do I Start?

This above all: To thine own self be trueThis above all: To thine own self be true

Polonius to Laertes : Hamlet Act 1, scene 3Polonius to Laertes : Hamlet Act 1, scene 3

Self Reflection: What are my needs?

Short term: Research goals, clinical training

Long Term: Professional and personal development

Where to look?Where to look?

Academic/Research Path:Academic/Research Path:

Mentoring ProgramsMentoring Programs

Lead Investigator (research project), Faculty Lead Investigator (research project), Faculty member, Postmember, Post--doc fellowsdoc fellows

Ask your fellowship director, senior fellows, Ask your fellowship director, senior fellows, other faculty membersother faculty members

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Where to look?Where to look?

Clinical Educator/Private Practice Path:Clinical Educator/Private Practice Path:

Recent faculty on clinical educator pathwayRecent faculty on clinical educator pathway

Local/Private practice GI in communityLocal/Private practice GI in community

Fellowship Director, Medical School Faculty, Fellowship Director, Medical School Faculty, Senior FellowsSenior Fellows

How Do I Ask?How Do I Ask?

Be PreparedBe Prepared !! -- Be able to outline your short and Be able to outline your short and long term goals, what will it take to reach these goals long term goals, what will it take to reach these goals and how can your mentor help you to reach these goals and how can your mentor help you to reach these goals -- Personal Mission StatementPersonal Mission Statement

Set up a formal meeting/interview to discuss the Set up a formal meeting/interview to discuss the possibility of mentorshippossibility of mentorship

Be enthusiastic, honest, humbleBe enthusiastic, honest, humble

How Do I Make it Work?How Do I Make it Work?

Recognizing the Recognizing the ““ChemistryChemistry”” –– Does their style Does their style of teaching, communication match or clash with of teaching, communication match or clash with yours?yours?

Be active not passiveBe active not passive –– DonDon’’t expect your t expect your Mentor to setMentor to set--up everythingup everything

Be preparedBe prepared –– have an agenda, send any key have an agenda, send any key information in advanceinformation in advance

Multiple Mentors ?Multiple Mentors ?

“the assumption behind mentoring – ‘I’ll tether myself to one person who will take care of me’- is bankrupt. A better way is to build…a personal mosaic of influences, experts and guides.”

For Multiple NeedsFor Multiple Needs

““AA”” Good Mentor is Hard to FindGood Mentor is Hard to Find

Research NeedsResearch Needs –– Build and develop your Build and develop your critical thinking, research skills, interpretation of critical thinking, research skills, interpretation of the medical literaturethe medical literature

Personal NeedsPersonal Needs –– Balancing work and familyBalancing work and family

Career Planning NeedsCareer Planning Needs –– Teaches you how to Teaches you how to ““play the gameplay the game””, politics of academic medicine, , politics of academic medicine, business side of medicinebusiness side of medicine

TakeTake--Home MessagesHome Messages

A mentor is essential to a successful career A mentor is essential to a successful career

Mentees need to be diligent in seeking out these Mentees need to be diligent in seeking out these relationshipsrelationships

You may find/need several mentors along the You may find/need several mentors along the wayway

Maximizing the satisfaction and productivity of Maximizing the satisfaction and productivity of a successful mentora successful mentor--mentee relationship requires mentee relationship requires selfself--awareness, focus, mutual respect, and awareness, focus, mutual respect, and explicit communication about the relationship.explicit communication about the relationship.

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ReferencesReferences

Sambunjak D, Straus SE, Marusic A. Mentoring in Academic Sambunjak D, Straus SE, Marusic A. Mentoring in Academic Medicine: A Systematic Review. Medicine: A Systematic Review. JAMA 2006;296(9):1103JAMA 2006;296(9):1103--11151115..

Jackson VA, Palepu A, Szalacha L, Caswell C, Carr PL, Inui T. Jackson VA, Palepu A, Szalacha L, Caswell C, Carr PL, Inui T. ““Having the right chemistryHaving the right chemistry””: A qualitative study of : A qualitative study of mentoring in academic medicinementoring in academic medicine. Acad Med 2003;78(3):328. Acad Med 2003;78(3):328--34.34.

Rose GL, Rutstalis MR, Schuckit MA. Informal mentoring Rose GL, Rutstalis MR, Schuckit MA. Informal mentoring between faculty and medical students. between faculty and medical students. Acad Med Acad Med 2005;80(4):3442005;80(4):344--348.348.

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How to Read & Critically Appraise Medical Literature

Wallace Crandall, MDNationwide Children’s Hospital

How to Read & Critically Appraise Medical Literature (without a biostatistics degree)

Wallace Crandall, MDNationwide Children’s Hospital

Goals

Discuss one approach to becoming comfortable evaluating medical literature

Identify resources to help with this process

Resources

Users Guides to the Medical Literature I. How to Get Started

Getting Started Asking questions that are pertinent and answerable Tracking down articles

Three Questions Are the results of the study valid? What are the results? Will the results help me in caring for my patients?

Oxman AD, Sackett DL, Guyatt GH, JAMA 270(17), Nov 1993

Getting started

Asking questions that are pertinent and answerable More than just “reading” Relevant to your patient

Tracking down articles

Oxman AD, Sackett DL, Guyatt GH, JAMA 270(17), Nov 1993

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Getting started

Asking questions that are pertinent and answerable “What should I do for my 15 yo IBD patient with

low bone mineral density?” “Should I give him a bisphosphanate?” “Are bisphosphanates effective for low BMD?” “Are bisphosphanates safe and effective in

improving low BMD in adolescents with IBD?”

Oxman AD, Sackett DL, Guyatt GH, JAMA 270(17), Nov 1993

Getting started

Tracking down articles Systematic reviews (eg Cochrane review) Practice Guidelines “High Impact” journals

NEJM 51.2 JAMA 31.7 Gastroenterology 12.5 Am J Gastro 6.1 Pediatrics 4.7 J Peds 4.1 JPGN 2.1

Three Questions(last year it was 10)

Are the results of the study valid? What are the results? Will the results help me in caring for my

patients? You still have to make a decision for your patient,

regardless of the evidence

These are often not “yes/no” answers Specific approach will vary by study type

Oxman AD, Sackett DL, Guyatt GH, JAMA 270(17), Nov 1993

Resources

Users Guides to the Medical Literature IIA. How to use an article about therapy or

prevention- Are the results of the study valid

IIB. How to use an article about therapy or prevention- What were the results and will they help me in caring for my patients

Guyatt GH, Sackett DL, Cook DJ JAMA 270(21) Dec1993; Guyatt GH, Sackett DL, Dook DJ JAMA 271(1) Jan 1994

Resources IIIA/B. How to use an article about a diagnostic

test VIIIA/B. How to use a clinical practice guideline XIV. How to decide on the applicability of clinical

trial results to your patient XVI. How to use a treatment recommendation XVII. How to use guidelines and recommendations

about screening How to use an article about quality improvement

(Nov, 2010)

Therapy or Prevention: Are the Results of the Study Valid?

Do results provide an unbiased estimate of treatment effect? Was the question appropriately framed?

Were patients randomized? Were patients, study personnel “blinded”? Were groups similar at start of trial? Were groups treated equally?

Was the evidence appropriately collected and summarized? Were all patients accounted for? Was follow up complete? Were patients analyzed in groups to which they were

randomized?

Guyatt GH, Sackett DL, Cook DJ JAMA 270(21) Dec1993

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What are the results? How large was the treatment effect?

Point estimate The best estimate of treatment effect (not the actual treatment

effect, just “in the neighborhood”) Absolute risk reduction, relative risk, relative risk reduction, etc

How precise was the estimate of effect? Confidence intervals

“The neighborhood” in which lies the actual treatment effect If crosses “0” or “1”, cant be assured of effectiveness If positive study, examine the low end of CI to consider clinical

significance If negative study, examine upper end of CI to assess for

possible clinical significance. If yes, study failed to exclude an important effect

Guyatt GH, Sackett DL, Dook DJ JAMA 271(1) Jan 1994

Will the results help me in caring for my patients? Can the results be applied to my patient?

Would your patient have been eligible? Is there a compelling reason why results should not be

applied to my patient? Beware of sub-group analysis (“dredging”)

Were all clinically important outcomes considered? Be cautious of “substitute end points” Balance measures

Are likely benefits worth the potential harm and cost? NNT NNH

Guyatt GH, Sackett DL, Dook DJ JAMA 271(1) Jan 1994

Statistics

“He uses statistics as a drunken man useslamp posts – for support rather than forillumination.”

Andrew Lang

Understanding What We Read

Healthy 45 yo male undergoes a screening test for a specific cancer Occurs in 1 in 1000 people of his age 99% sensitive (ie only 1% false negative) 98% specific (ie only 2% false positive)

His test comes back positive What is the probability that he has

cancer? PPV 4.7%

Beck-Bornholdt HP, Dubben HH. p<0.05! So what?- What we can learn from the statistician

Interpreting a Positive Clinical Trial

You are reviewing a manuscript of a perfectly designed, well conducted, carefully evaluated study

Results Treatment A is significantly better than

Treatment B, p=0.03

What does this mean?

Beck-Bornholdt HP, Dubben HH. p<0.05! So what?- What we can learn from the statistician?

Sterne JAC, Smith, GD. BMJ 322 Jan 2001.

Interpreting a Positive Clinical Trial

Assumptions: 10% of experimental treatments are better

than standard treatment (fair estimate) Power of 80%

PPV 64% 1/3 of “perfect” studies with positive

results are misleading

Beck-Bornholdt HP, Dubben HH. p<0.05! So what?- What we can learn from the statistician?

Sterne JAC, Smith, GD. BMJ 322 Jan 2001.

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Sterne JAC, Smith, GD. BMJ 322 Jan 2001. Sterne JAC, Smith, GD. BMJ 322 Jan 2001.

Sterne JAC, Smith, GD. BMJ 322 Jan 2001.

SONIC- Clinical Remission Without Corticosteroids at Week 26

Primary Endpoint

30

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AZA + placebo IFX + placebo IFX+ AZA

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51/170 75/169 96/169

Gastroenterology. 2009; 136 (5): Suppl 1. A-116.

Recommendations

Become very good at the fundamentals Regular “exercise”

Then use the excellent available resources to start filling in any “holes”

Be thoughtful, critical, … and realistic

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Teaching Talk: Dos and Don’ts

Michael Narkewicz MDProfessor of Pediatrics

Hewit Andrews Chair in Pediatric Liver DiseaseFellowship Program Director

Goals

• Outline of Adult Learning

• Tips for a Teaching Talk

• Examples

Understand Adult Learning

• Adults:

– have a specific purpose in mind;

– are voluntary participants in learning;

– require meaning and relevance;

– require active involvement in learning;

– need clear goals and objectives;

– need feedback;

– need to be reflective.

Get the Details of Your Talk

• Who is the audience:– Make your talk pertinent to the audience– Parents vs Nursing vs Medical Students vs Residents vs PCPs 

• How much time do you have– Major complaint: Talked too long and too fast– 1 slide per minute of your talk

• What are the goals of asking you to talk?– Develop talk goals– Adults need clear goals

Often Helps to Have a CaseAdults Require Meaning and 

Relevance • Tips

– Collect images from interesting cases: never know when you may use them

• I have a folder with images from cases (XRays, Endoscopy images, Path images)

– Cases act as a hook to keep interest and shows relevance

Example

• Insert the CT image of the liver tumorPUB MED:24,641 articles, 1645 in children

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HCC in heart (HBV)

Malignant Thrombus

Define the Goals

• State the Goals up front:

• Maximum Three

• Pancreatitis

– Review definitions

– Understand the evaluation

– Know the management options

Know your subject

• Review the literature for guidelines, reviews

• By definition, most times you will know more than the others.

Make the talk interactive

• Set up the talk to allow participation– What would you do next?

– What are the top items on the differential diagnosis?

– How many people would get X?

Some key items not to do

• I know that you can’t see this table but

• Use red and green (color blind issues)

• Put key items in a corner of a slide

Sequence data

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Sequence Data

• There are 25 key mutations in ferroportin

• The amino acids involved in the mutations are similar between humans and other species including mice and xenopus

• Mutations occur at key parts of the protein in this autosomal dominant 

Busy table

Examples of common mutations

• 36 Mutations in Ferroportin

• 10 predicted to cause disease– 5 non classical

• Carrier rate is <1:150 for each

• Many mutations with unknown effect

Use arrows and highlights in the talk

Use arrows and highlights in the talk Keep the focus of the slide in the  center

Don’t put the key element on the side or in the corner

Use the right font for the job

18 20 24     28    32  36  40

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Leave time for Questions

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Twelve tips on teaching the consultant teachers toteach

DAVID WALLUniversity of Birmingham and West Midlands Deanery, Birmingham, UK

Introduction

There has been concern at the standard of clinical teaching

in hospitals in the United Kingdom for some time (Hore,

1976; Parry, 1987; Lowry, 1992) . Teaching by humiliation

and ritual sarcasm, and the demotivating effect this may be

having on junior doctors and medical students have been

described (Metcalfe & Matharu, 1995). Similar problems

exist in North America, where a literature review (Irby,

1995) showed that undergraduate and postgraduate medical

teaching was variable, unpredictable, lacked continuity and

gave virtually no feedback. In Australia, similar problems of

little feedback, poor supervision and haphazard assessment

of junior doctors have also been described (Rotem et al.,

1995), which were worse in large teaching hospitals.

To try to address these issues and improve teaching and

the educational climate in hospitals, the Standing Committee

on Postgraduate Medical and Dental Education (SCOPME)

issued a report on Teaching Hospital Doctors and Dentists to

Teach: Its Role in Creating a B etter Learning Environment

(SCOPME, 1992). Following this publication, there was an

upsurge in the level of professional debate about the need to

improve clinical teaching (Lowry, 1992, 1993). In a review

of current medical education, Coles (1993) concluded that

a change in educational and teaching methods, rather than

a rearrangement of course content, was needed. He drew

attention to the teaching culture, and advocated methods

that re¯ ected the aims and objectives of the curriculum,

and the principles of adult learning, more small-group work,

and problem-based learning. He maintained that it was

imperative that teachers understand the principles of adult

learning, curriculum development, evaluation and assess-

ment.

Several initiatives for `Training the Trainers’ or perhaps

the better named `Teaching the Teachers’ are already in

place (Batstone, 1996). The Universities of Dundee and of

Wales (in Cardiff) have had courses leading to qualifications

in medical education for many years, even before the

SCOPME report was published in 1992. Several Deaneries

and Royal Colleges are now beginning to run courses to

help consultants improve their teaching skills (Biggs et al.,

1994; Peyton, 1996, 1998; and Dennick, 1998). There is an

increasing interest in the need for training in teaching skills.

Some of these courses are short, one- or two-day courses

for the busy consultant. The consultant is now called upon

to be a good educational supervisor for the house officer

(General Medical Council, 1997), to supervise and appraise

the senior house officer (General Medical Council, 1998),

and to assess the learning needs, appraise and assess the

specialist registrar (Department of Health, 1996). Most

consultants have no training in these new skills, so how may

we set up, run and evaluate such courses for the average

busy consultant in our hospitals?

This article contains some advice, based on educational

principles, on research carried out (Wall and McAleer, 1999),

and on experiences in running Teaching theTeachers courses

for consultants in all specialities in the West Midlands over

the last 3 years. This article offers 12 tips for those setting

up and running such courses.

W hat shall we teach? Establishing the curriculum for

your course

Educational planning based on sound principles and increas-

ingly on research evidence will ultimately lead to more effec-

tive and efficient medical education in the future (Bligh,

1999). When planning a curriculum for a course, Harden

(1986) described 10 questions to ask while carrying out this

task. These were related to needs, aims and objectives,

content, organization of content, educational strategies,

teaching methods, assessment, communication of curriculum

details, the educational climate, and progress Ð how to

manage it. Going back to the beginning, Dunn et al. (1985)

described several methods for deriving a curriculum. The

best methods included the Delphi technique (with opinions

from experts), critical incident studies, and behavioural event

analyses with star performers in the area. However, there

may be no need to derive the curriculum from scratch.

Recent research has identi® ed several key themes which

both consultants and junior doctors think are very important

to be taught on such courses (Wall & McAleer, 1999).

These are:

· giving feedback constructively;

· keeping up to date as a teacher;

· building a good educational climate;

· assessing the trainee;

· assessing the trainee’s learning needs;

· practical teaching skills.

These will give a start. However, you may need to focus the

curriculum more towards the particular speciality concerned,

using perhaps a Delphi technique, or interviews with star

performers in that speciality (Dunn, Hamilton and Harden,

1985). For example, urologists may place more emphasis

on teaching practical skills effectively than do psychiatrists.

Remember that effective needs assessment involves teachers,

Cor re sp ondence: D r D avid Wall, D eputy Regional Postg ra duate Dean,

Postgraduate Dean’s office, The M edical School, University of Birmingham,

Edgbaston, Birm ingham B15 2TT, UK. Tel: 0121 414 6892; fax: 0121 414

3155; email: [email protected]

Medical Teacher, Vol. 21, No. 4, 1999

ISSN 0142-159X print/ISSN 1466-187X online/99/040387 ± 06 ½ 1999 Taylor & Francis Ltd 387

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learners and experienced programme planners in a construc-

tive dialogue (Laxdal, 1974).

Tip 1

Establish your curr iculum based on sound

educational principles, and tailor this to the specific

group of consultants on your course.

Setting the learning objectives

Stenhouse (1975), in a major work on curriculum develop-

ment, stressed the importance of curriculum development

resting on the translation of general statements of aims into

much more speci® c and precise behavioural objectives.The

objectives model has considerable power. Objectives have

been described as the ª light and heat in educational

technologyº (Rowntree, 1982). Outcomes of the course

should be stated precisely, and the teaching planned and the

educational experiences offered on the course should ® t in

with these outcomes (Harden et al., 1999).

Therefore the course timetable will state the aims and

the objectives of the course. For example, a practical

teaching-skills course may have a broad aim, and much

more precise behavioural objectives for what the candidate

will be able to do at the end of the course. This could be:

Aim:To give candidates the opportunity to explore

the knowledge and skills of a variety of teaching

methods.

Objectives: At the end of the course the participants

will be able to:

(1) demonstrate the principles of teaching a practical

skills effectively;

(2) demonstrate how to give feedback constructively

and effectively.

(3) and so on.

Tip 2

Set the learning objectives based on the curriculum

in terms of what the candidates will be able to do

at the end of the course. Plan the teaching on your

course around these stated objectives.

The use of active learning methods

Coles (1993) suggested changes to the educational methods

used in medical teaching and learning. He emphasized that

teaching methods must re¯ ect the aims and the objectives

of the curriculum, and that they embody the principles of

adult learning (Brook® eld, 1986). Such methods include

doctors taking more responsibility for their own learning,

with more small-group work, discussions, problem-based

learning, and fewer lectures and formal teaching sessions.

Teachers do need to understand the new relationship

between teacher and learner, with the learners gradually

assuming more control over their education themselves.

Teachers are facilitators of learning, and may be helped by

using small-group workshops on a course to stimulate their

thoughts on effective teaching and learning (Price & Miflin,

1994; Walton, 1997).

In our own courses, we use a mixture of short, 15-minute

keynote talks, small-group work with tasks, plenary sessions,

role plays, and practical teaching exercises. We emphasize

the principles of adult learning (Brook® eld, 1986) very early

on in the course as:

· voluntary participation;

· mutual respect between teacher and learner and among

learners;

· collaboration between teacher and learner and among

learners;

· action and re¯ ection;

· critical re¯ ection;

· nurturing of self-directed adults.

So, candidates on such courses are working to tasks set, to

solving problems, and are actively involved in the course as

a deliberate educational strategy.

Tip 3

Use active learning methods such as small-group

work, role plays, practical exercises and problem

solving, based on the aims and objectives of the

course curriculum, and on the principles of adult

learning.

The educational climate

Many studies have described a poor educational climate in

our hospitals. Such problems have included poor or no

feedback, poor supervision, variable and unpredictable

teaching, lack of continuity, and teaching by humiliation,

shouting and ritual sarcasm (SCOPME, 1992; Metcalfe &

Matharu, 1995; Rotem et al., 1995; Guthrie et al., 1995).

When feedback was given, it often concentrated only on

what was done wrong (Dillner, 1993).

So, we aim to explain in simple terms what the

educational climate is. Many consultants do recognize this,

but will often use other words to describe the concept, such

as `ambience’ , `environment’ or `atmosphere’ . We talk of the

climate in terms of physical, emotional and intellectual

attributes. Many are surprised that the educational climate

can indeed be measured, using a valid and reliable tool, the

Dundee Ready Educational Environment Measure or DREEM

(Roff et al., 1997).

We aim to provide a good educational climate on our

courses. It is important to practise what you preach, and set

up the course in a pleasant setting, with good facilities

(especially enough small rooms for breaking up into small

groups), adequate parking and directions, good communica-

tions, good handout packs, and a fr iendly relaxed

atmosphere. Some humour is important (Ziegler, 1998),

and can make a valuable contribution to the educational

process. It has been shown to reduce stress and anxiety,

build con® dence and reduce boredom. Remember that some

consultants coming on such courses may be ver y

apprehensive, and have not for a long time been in the

learner role, or been in a small-group setting. They should,

it is hoped, go home at the end having enjoyed the day and

had some fun, as well as learned something!

Tip 4

Pay attention to the educational climate of your

course. Practise what you preach, and aim for a

friendly, supportive and non-threatening environ-

ment for teaching and learning. It should be fun.

Giving feedback constructively

This theme was top of the list of 15 educational themes

rated by 441 consultants and junior doctors in the West

D.Wall

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Midlands, when asked what should be taught to consultants

on a teaching the teachers course (Wall & McAleer, 1999).

Trainees do complain of lack of feedback, of no feedback at

all, or feedback given negatively, sometimes by humiliation,

sarcasm, sexism and shouting (Metcalfe & Matharu, 1995;

Guthrie et al., 1995; Paice et al., 1997).

Feedback given constructively does improve learning

(Rolfe & McPherson, 1995), and this is true in very many

teaching and learning situations (Black & Wiliam, 1998).

There are methods of giving feedback constructively. The

well-known `Pendleton’s rules’ (Pendleton et al., 1984), and

the `One Minute Teacher’ (Gordon et al., 1996) are two of

these, which we use on our courses and have found to be

valuable. Both depend on giving positive support and

reinforcement for things that were right, and then making

constructive suggestions for correcting mistakes.Very simply,

the One Minute Teacher consists of ® ve micro-skills for

clinical teaching. These are:

· Get a commitment:What is going on?

· Probe for supporting evidence.

· Teach general rules and principles.

· Reinforce what was right.

· Correct mistakes in a constructive way. ª Next time this

happens why not try this instead . . . .º

We teach these early on in our courses, because we use them

in the small-group work and microteaching exercises when

we ask candidates to give constructive feedback to their

peers on their efforts. Sometimes, individuals go straight for

the criticisms, and are then asked to stop and are gently

reminded to go back through the steps of Pendleton’s rules,

and start again. So, as well as teaching about constructive

feedback, we get candidates to give constructive feedback

during the course, and have it given to then by their peers as

well.

Tip 5

Emphasize the crucial importance of g iving

feedback constructively. Use models of giving

feedback to help the candidates do this on the

course, when giving and receiving feedback to and

from each other on activities they all do on the

course.

Teaching of practical skills

Junior doctors value this skill in their teachers very highly,

much more so than do their consultant teachers themselves

(Wall & McAleer, 1999). A simple model of teaching

practical skills is the one used by the Royal College of

Surgeons of England on their `Training theTrainers’ courses

(Peyton, 1996, 1998). The basic elements are the prepara-

tion (set), the procedure itself (dialogue), and the summary

(closure). In teaching the skill in the dialogue, a four-step

model is used:

· The teacher does the procedure at normal speed.

· The teacher does the procedure again, and talks through

it, performing and explaining each step.

· The teacher does it again, with the learner talking through

it and explaining the steps.

· The learner now does the procedure, and talks it through

as well, explaining the steps.

It is very important to give feedback constructively, using

the ideas described in Tip 5 above. Leave time for ques-

tions, and remember to plan the next learning experience at

the end (closure).

We do these exercises in groups of three (trios). Each

candidate is asked to bring to the course all the materials to

give a ® ve-minute teaching session on a practical skill (prefer-

ably not medical). Each person in the group will have a turn

at being a teacher, a learner and an observer in this session,

with feedback given on performance using Pendleton’s rules.

These have been very enjoyable and entertaining sessions.

Complete novices have been able, after 5 minutes of

one-to-one teaching, to perform quite complex tasks, such

as tie a trout ¯ y, put on a turban, tie a bow tie, make a trifle,

play a penny whistle, and prune an apple tree branch! Many

candidates have re¯ ected on these sessions, and have said

that they will go back to their own hospitals and prepare

their teaching much more thoroughly and make sure they

are fully prepared to teach.

In this session it is crucial that everyone brings with

them a practical skill to teach. The exercise is wholly

dependent on this, so we write a reminder, and ring them all

up just before the course starts as well. These measures

usually work!

Tip 6

A practical teaching skills exercise in the course is

very valuable, and does make some good

educational points. Make sure you know all the

steps, and can demonstrate the procedure yourself

® rst. Make sure everyone brings along a practical

skill, and remind them of this before they come.

Role play and appraisal practice

An ancient Chinese proverb gives the following educational

advice:

I hear and I forget

I see and I remember

I do and I understand

When teaching and learning about appraisal and how to

carry out an appraisal with a trainee, we have found that a

combination of a keynote talk, a video demonstrating the

techniques, and some role-play appraisal practice works well.

It is necessary to explain the de® nition and the principles of

good appraisal practice (SCOPME, 1996), its purposes,

and how to use appraisal to deal with problems. The Video

Arts videotape entitled `The Dreaded Appraisal’ is an excel-

lent illustration of both how not to do it, and then how to do

it correctly. It lasts 30 minutes, makes only a few key points,

does this very well, and is entertaining to watch. Finally we

ask candidates to play either an appraiser or an appraisee, in

a small-group setting. Case scenarios have been prepared

beforehand by the organizers to illustrate particular points

(Skelton & Hammond, 1998) and problems that may be

encountered with trainees. They are based on real-life situ-

ations that we have experienced in the past, suitably

anonymized. Some scenarios are applicable to any speciality,

such as the trainee who is very polite to the consultant, but

rude, aggressive and awful to everyone else. Others do need

to be speciality speci® c, so it pays to enlist the help of

colleagues in that speciality in writing and adapting case

scenarios when planning the course.

How are the role play sessions structured? Case scenarios

Twelve tips on teaching teachers to teach

389

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are given out, and candidates divided into groups of three

(trios). In turn, each is asked to be an appraiser, an appraisee

and an observer. Feedback is given using Pendleton’s rules

again (Pendleton et al., 1984). Facilitators watch these

sessions, to help candidates understand the tasks and roles

to be played. It does become very realistic. In a one-hour

session, each of the three candidates will have a turn at

being a consultant appraiser, a trainee being appraised and

an observer, and have done three of the case scenarios.This

is real active learning, and is usually a lot of fun.

Tip 7

Prepare case scenarios carefully, making sure they

are relevant to the candidates’ own experiences.

Explain the purposes of the session carefully

including the giving of feedback to each other

using a method of giving feedback constructively

(such as Pendleton’s rules).

Evidence-based education

Sometimes candidates ask for evidence from the educational

literature to support a concept or statement made on the

course. It is useful therefore to provide a reading list of key

articles and books that interested candidates may look at

afterwards, and some key references to support what you

are going to say on the course. Such key references are

included in the handout pack given out at the beginning of

the course.

We welcome the movement towards evidence-based

medical education, including the new series in Medical

Teacher in 1999 entitled `Best Evidence Medical Educa-

tion’ (Harden, 1998) Much evidence is currently spread

widely over medical education journals, specialist and general

medical journals, and specialist and general education

journals. This makes it very difficult to pull together good

evidence to inform best practice. It will be of great bene® t

to have such evidence available to us.

However, there is good evidence already for some of

what is being done. For example, Rolfe & McPherson (1995)

discussed giving feedback constructively, with the bene® ts

of improved learning outcomes, a deeper approach to

learning , active pursuit o f knowledge and improved

competence at least in the short term. Further evidence in

the same area came from a large review of the educational

literature (Black & Wiliam, 1998), with 250 references

looking at many controlled studies.This review did confirm

that giving feedback constructively did work, and gave

substantive learning gains.

Also, there is evidence that the `student centred ’

curr iculum does have bene ® ts compared with the

`traditional’ curriculum. Studies show no differences in

marks for students on the new curr iculum, despite

widespread differences in curriculum design (Ripkey et al.,

1998). H owever, the `traditional’ students do suffer

disadvantages, with such students showing poorer moral

reasoning skills, less desirable modes of learning, and

increased stress (Bligh, 1999).

So we do need to be familiar with the educational

literature, base our ideas on best educational evidence, and

be able to suggest further reading to candidates in such

areas.

Tip 8

Base your course curriculum on best evidence

medical education. Have your evidence ready for

the topics that will be taught on the course. Ideally

put these references in the handout packs, and

then they are there ready for you to refer to during

the course.

Educational concepts, maps and models

A criticism of educationists, especially by clinical colleagues,

is the supposed use of jargon (Harden, 1998). While this

may be the case, clinical medicine is not without its own

considerable amounts of jargon, which is unintelligible to

others, even doctors in other specialities in medicine!

We aim to present concepts, maps and models which are

as simple as possible, and try to relate these to everyday

situations in medical practice. For example, the educational

cycle may be simpli® ed to four key steps and six key words

as below:

· assess needs;

· set objectives;

· methods;

· assessments.

Much of what we have done is based on this simple model,

as is this paper. Again, the principles of adult learning may

be simpli® ed to a few statements (see above), and the same

may be done for models of giving feedback, and for teaching

a practical skill, as has already been described.

As well as knowing what the model is, we design small-

group activities where candidates do actually use the models

in these activities on the course. This does reinforce the

concepts we are trying to bring to their attention. Thus we

do use structured feedback using Pendleton’s rules, and we

do use practical skills teaching using the model already

described and so on.

We explain simply what assessment, appraisal and evalu-

ation mean. For those who seem to use the terms

interchangeably, sometimes within the same sentence, we

point out that while bilirubin and alkaline phosphatase are

both liver function tests, they are not the same.They cannot

be interchanged, if we want others to understand what we

are talking about. We explain what aims and objectives are,

and illustrate this by looking at a simple First Aid Course. It

is then very clear that the objectives are `what the candidate

may be expected to do at the end of the course’ .

Tip 9

Keep concepts, maps and models as simple as

possible. Illustrate your maps and models with

examples that your course participants can follow

easily, often from clinical situations.

Evaluations

Evaluation of these courses, by the course participants, the

teachers themselves and by the providing organization which

pays for the courses, is an important part of the curriculum

(Harden, 1986).

We give a simple de® nition of evaluation as `measuring

the teaching’ and stress that it is de® nitely not another word

for `assessment’ of the learners. Evaluations may be by the

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learners themselves, by the teachers on the course, by peers

(including external bodies such as the Royal Colleges and

the General Medical Council), and by oneself as self-

evaluation and re¯ ection.

We have used a simple one-page A4 size evaluation form

with ideas and questions chosen from an evaluation design

pack (Grant et al., 1993), and from a guide to good assess-

ment practice (Jolly & Grant, 1997). This ® ts in with the

`keep it simple’ philosophy on these courses. In addition,

space is provided for free comments. This has given us

much valuable information and feedback, and has enabled

us to improve courses as a result of these ideas. For example,

the videotape `The Dreaded Appraisal’ was one such idea

that came from a free comment on one of the evaluation

forms.

In addition, even though most people have enjoyed the

course and found it useful, we still need to know if these

ideas are taken back and put into practice. A longer term

follow-up evaluation is very useful here. We have been able

to demonstrate in the West Midlands that consultants did

take these ideas on board, and after 6± 12 months after the

course, had put them into practice in their day-to-day

teaching (Whitehouse, 1997).

All this does take time and effort. Nevertheless it is an

important part of the educational strategy of improving

consultants’ teaching knowledge and skills. There is a need

for more research in this area to be certain that there is a

change occurring as a result of the efforts put in.

Tip 10

Evaluation is an important part of your course.

Keep the evaluation simple, anonymous and easy

to ® ll in. Have some space for free comments on

the form. In addition, do some longer term follow

up to see if ideas have been taken on board and

changes to educational practice made.

W here next? How to keep the momentum going

Much to our delight, many consultants have become

completely enthused by and very keen on learning more

about medical education. For some, this seems to be similar

to the `conversions’ described in the social anthropology

literature (Coffey & Atkinson, 1996).

What can be done to maintain enthusiasm once it has

been generated in the ® rst place? Maybe the consultant

trainers’ group is one way to do this. Whitehouse (1997)

described that after an intensive educational course, a group

of Warwickshire consultant trainers continued to meet

regularly and discuss educational initiatives they have tried,

and derive great bene® t from peer support in such a group.

Rayner et al. (1997) described a similar group of consult-

ants at Birmingham Heartlands Hospital, who continue to

meet after a series of educational courses run by the Staff

Development Unit of the University of Birmingham.

General practitioners will recognize these initiatives as

`trainers’ workshops’ , where trainers meet to discuss ideas,

share problems and successes, and derive peer support for

their role as a teacher from the group.

In addition, many have enrolled for university quali® ca-

tions in medical education. For many years the universities

of Dundee and of Wales (in Cardiff) have run such courses

(Batstone, 1996), and have trained many medical educa-

tors. Their knowledge and skills of medical education are

now increasingly valued (Bligh, 1999). The postgraduate

deans do need to support these initiatives if funds will allow,

and nurture such individuals as extremely valuable

educational resources.

These areas do need further research.What does enthuse

such individuals? Why do they seem to come from some

specialities and not others? Why do the ear, nose and throat

(ENT) surgeons, the paediatricians and the obstetricians

lead the ® eld (in the West Midlands at least) in the numbers

studying for educational quali® cations in medical educa-

tion?

Tip 11

Have a strategy to keep the momentum going.

Capture the enthusiasm of those who develop an

interest in medical education, as they are one of

our most valuable resources for the future.

Research and development

There remains much work to do in this area of medical

education. Researchers are now shedding much welcome

new light on many of the `traditional’ educational practices.

New techniques and new ideas are being introduced to

everyday medical teaching in our hospitals, with evidence to

support such initiatives (Bligh, 1999).

As well as the curriculum content and objectives, the

culture and values (the educational climate) of the institu-

tion are also very important. Research has shown that student

choice of a career in general practice, for example, is

in¯ uenced by the culture of the medical school concerned

being supportive towards general practice (Lambert et al.,

1996).These factors are important and do need researching.

There are still unanswered questions about the

pre-registration year reforms (General Medical Council,

1997), the changes to specialist registrar training (Depart-

ment of Health, 1996), and the very recently published

recommendations for the senior house officer years, The

EarlyYears (General Medical Council, 1998). Some evalua-

tion work is already going on here, but such research does

need to continue, to expand and to be funded adequately.

Tip 12

Research and development is an integral part of

new developments and the new techniques in

medical education. Research should be seen as an

essential part of the overall education strategy of

the teaching-the-consultant-teachers movement,

and supported ® nancially.

Notes on contributor

DAVID WALL FRCP, FRCGP, MMEd is a general practitioner in

Sutton Cold® eld in the West Midlands. He is also deputy regional

postgraduate dean for the University of Birmingham and West

Midlands Deanery. His main interests in medical education are in

curriculum studies, educational needs of GP non-principals and

teaching the consultant teachers.

References

BATSTO NE, G. (1996 ) Training for trainers does exist in Britain,

B ritish Medica l Journal, 312, p. 1301 .

Twelve tips on teaching teachers to teach

391

Med

Tea

ch D

ownl

oade

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ahea

lthca

re.c

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rsity

of

Col

orad

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12/

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r pe

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se o

nly.

59

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BIGGS, J.S.G., AGGER, S.K., DENT , T.H.S., ALLER Y, L.A. & COLES,

C. (1994) Training for medical teachers: a UK survey, Medical

Education , 28, pp. 99 ± 106.

BLACK, P. AND W ILIAM , D. (1998) Assessment and classroom learning,

Assessment in Education, 5, pp. 7± 73.

BLIGH , J. (1999 ) Curriculum design revisited (editorial), Medical

Education, 33, pp. 82 ± 85.

BROOKFIELD, S.D. (1986) Understanding and Facilitating Adult Learning

(Milton Keynes, Open University Press).

CO FFEY, A. & ATKINSON, P. (1996) Making Sense of Qualitative Data

(London, Sage Publications).

COLES, C. (1993) Developing medical education, Postgraduate Medical

Journal, 69, pp. 57 ± 63.

DEN NICK , R. (1998 ) Teaching medical educators to teach: the

structure and participants’ evaluation of the Teaching Improve-

ment Project, Medica l Teacher, 20, pp. 598± 601.

DEPAR TM ENT OF HEA LTH (1996) A Guide to Specialist Registrar

Training (London, Department of Health).

DILLNER , L. (1993) Senior house officers: the lost tribe, British Medical

Journal, 307, pp. 1549 ± 1551.

DUNN , W.R., HAMILTON , D.D. & HARDEN , R.M. (1985 ) Techniques

for identifying competencies needed of doctors, Medical Teacher, 7,

pp. 15± 25.

GRANT , J., EVANS , K., MAY, R., SAVAG E, S. & SAVAG E, R. (1993) An

Evaluation Pack for Education in General Practice (London, Joint

Centre for Education in Medicine).

GENER AL M ED ICAL COUN CIL (1997) The New Doctor (London,

General Medical Council).

GENERAL MEDICAL COUNC IL (1998) The EarlyYears (London, General

Medical Council).

GORDO N, K., M AYER , B. & IRBY, D. (1996) The One Minute Preceptor:

Five Microskills for Clinical Teaching (Seattle, USA, University of

Washington).

GUTHR IE, E.A., BLACK, D., SHAW, C.M., HAMILTON , J., CREED , F.H.

& TO M E N SO N , B. (1995) Embarking on a medical career:

psychological morbidity in ® rst year medical students, Medical

Education , 29, pp. 337± 341.

HARDEN , R.M. (1986) Ten questions to ask when planning a course

or curriculum, Medica l Education, 20, pp. 356± 365.

HARDEN , R.M. (1998) Medical teacher (Editorial), Medica l Teacher,

20, pp. 501± 502.

HARDEN , R.M ., CROSBY, J. & D AVIS, M.H. (1999) Outcome based

education, Medical Teacher, 21 (1), pp 7± 14.

HORE, T. (1976) Teaching the teachers, Anaesthes ia and Intensive

Care, 4, pp. 329 ± 331.

IRBY, D.M. (1995) Teaching and learning in ambulatory care settings:

a thematic review of the literature, Academic Medicine, 70, pp.

898± 931.

JOLLY, B. & GRANT , J. (1997) The Good Assessment Guide. A Practical

Guide to Assessment and Appraisa l for Higher Specialis t Training

(London, Joint Centre for Education in Medicine).

LAMBER T, T., GOLDACRE, M. & PARKH OUSE, J. (1996 ) Career prefer-

ences and their variation by medical school among newly quali® ed

doctors, Health Trends, 28, pp. 135 ± 144.

LAXDAL , O.E. (1974 ) Needs assessment in continuing medical educa-

tion: a practical guide, Journal of Medical Education, 57, pp. 827± 834.

LOW R Y, S. (1992) What’s wrong with medical education in Britain?,

British Medical Journal, 305, pp. 1277 ± 1280 .

LOW R Y, S. (1993) Teaching the teachers, British Medica l Journal, 306,

pp. 127± 130.

METC ALFE, D.H. & M ATHAR U, M. (1995) Students’ perceptions of

good and bad teaching: report of a critical incident study, Medical

Education , 29, pp. 193± 197.

PAICE, E., MOSS, F., WEST, G. & GRANT , J. (1997) Association of a

log book and experiences as a pre-registration house officer:

interview study, British Medical Journal, 314, pp. 213± 215.

PARR Y, K.M. (1987 ) The doctor as teacher, Medical Education, 21,

pp. 512± 520.

PENDLET ON , D., SCHOFIELD, T., TATE , P. & HAVELOC K, P. (1984) The

Consultation: an Approach to Teaching and Learning (Oxford, Oxford

Medical Publications).

PEYTO N, R. (1996 ) College has found strong demand for training

programmes, British Medical Journal, 312, pp. 1301 ± 1302 .

PEYTO N, J.W.R. (1998) Learning and Teaching in Medical Practice

(Rickmansworth, Manticore Europe).

PRICE, D. & M IFLIN, B. (1994 (1)) Teaching the teachers: a new

approach to facilitating learning in student± patient interactions,

Medical Journal of Australia, 161, p. 181.

RAYNER , H., MO R TON , A., M CCULLOCH , R., HEYES, L. & RYAN , J.

(1997) Delivering training in teaching skills to hospital doctors,

Medical Teacher, 19, pp. 209± 211.

RIPKEY, D.R., SWANSO N, D.B. & CASE, S.M. (1998) School to school

differences in Step 1 performance as a fraction of curriculum type

and use of step 1 in promotion/graduation requirements, Academic

Medicine, 73, supplement 10, s91± 93.

ROCHE, A.M ., SANSON-FISHER, R.W. & COCKBUR N, J. (1997) Training

experiences immediately after medical school, Medica l Education,

31, pp. 9± 16.

ROFF , S., M CALEER , S., HARDEN , R.M ., AL-QAH TANI , M., AH MED,

U.A., DEZA, H., GROENEN , G. & PRIMPAR YO N, P. (1997) Develop-

ment and validation of the Dundee Ready Educational Environ-

ment Measure (DREEM), Medical Teacher, 19, pp. 295± 299.

ROLFE, I. & M CPHER SON, J. (1995 ) Formative assessment: How am

I doing?, Lancet, 345, pp. 837± 839.

ROTEM , A., GO DW IN, P. & DU, J. (1995) Learning in hospital settings,

Teaching and Learning in Medicine, 7, pp. 211 ± 217.

ROW NTREE , D. (1982) Educational Technology in Curriculum Develop-

ment, 2nd edn (London, Paul Chapman).

SCOPME (1992) Teaching Hospital Doctors and Dentists to Teach: its

Role in Creating a Better Learning Environment. Proposals for Consulta-

tion ± Full Report (London, Standing Committee on Postgraduate

Medical Education).

SCOPME (1996) Appraising Doctors and Dentists in training (London,

Standing Committee on Postgraduate Medical Education).

SKELTON , J.S. & HAMMOND , P. (1998) Medical narratives and the

teaching of communication in context, Medica l Teacher, 20, pp.

548± 551.

STENH OUSE, N. (1975) An Introduction to Curriculum Research and

Development (Oxford, Heinemann Educational).

WALL, D.W. & M CALEER , S. (1999) Teaching the consultant teachers:

identifying the core content, Medica l Education, 33 (in press).

WALTO N, H.J. (1997) Small Group Methods in Medical Education.

ASME Medica l Education Booklet No. 1, 1997 edition (Edinburgh,

Association for the Study of Medical Education).

WH ITEHO USE, A. (1997) Warwickshire consultants’ Training the

Trainers Course, Postgraduate Medical Journal, 73, pp. 35± 38.

ZIEGLER, J.B. (1998 ) Use of humour in medical teaching, Medical

Education, 20, pp. 341± 348.

D.Wall

392

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2008; 30: 347–364

AMEE GUIDE

AMEE Guide no. 34: Teaching in the clinicalenvironment

SUBHA RAMANI1 & SAM LEINSTER2

1Boston University School of Medicine, USA, 2University of East Anglia, Norwich, UK

Abstract

Teaching in the clinical environment is a demanding, complex and often frustrating task, a task many clinicians assume without

adequate preparation or orientation. Twelve roles have previously been described for medical teachers, grouped into six major

tasks: (1) the information provider; (2) the role model; (3) the facilitator; (4) the assessor; (5) the curriculum and course planner;

and (6) the resource material creator (Harden & Crosby 2000).

It is clear that many of these roles require a teacher to be more than a medical expert. In a pure educational setting, teachers

may have limited roles, but the clinical teacher often plays many roles simultaneously, switching from one role to another during

the same encounter. The large majority of clinical teachers around the world have received rigorous training in medical knowledge

and skills but little to none in teaching. As physicians become ever busier in their own clinical practice, being effective

teachers becomes more challenging in the context of expanding clinical responsibilities and shrinking time for teaching (Prideaux

et al. 2000). Clinicians on the frontline are often unaware of educational mandates from licensing and accreditation bodies as well

as medical schools and postgraduate training programmes and this has major implications for staff training. Institutions need to

provide necessary orientation and training for their clinical teachers. This Guide looks at the many challenges for teachers in the

clinical environment, application of relevant educational theories to the clinical context and practical teaching tips for clinical

teachers. This guide will concentrate on the hospital setting as teaching within the community is the subject of another AMEE

guide.

Introduction

Teaching in the clinical environment is defined as teaching

and learning focused on, and usually directly involving,

patients and their problems (Spencer 2003). The clinical

environment consists of inpatient, hospital outpatient and

community settings, each with their own distinct challenges.

It is in this environment that students learn what it means to

be a real doctor. Skills such as history taking, physical

examination, patient communication and professionalism are

best learned in the clinical setting, medical knowledge is

directly applied to patient care, trainees begin to be

motivated by relevance and self-directed learning takes on

a new meaning (Spencer 2003). Teaching in the clinical

setting often takes place in the course of routine clinical care

where discussion and decision-making take place in real

time. Often the teaching will centre on an analysis of actual

patient care that the student has undertaken. This is the most

common pattern for postgraduate trainees. Undergraduate

students benefit from additional sessions specifically planned

for teaching. These sessions may take place in the ordinary

clinical environment and make use of the patients who are

opportunistically available. They may on the other hand be

highly structured with particular patients brought up espe-

cially for the session.

The word ‘doctor’ is derived from the Latin docere, which

means ‘to teach’ (Shapiro 2001). Clinical teachers have a dual

role in medicine, to provide patient care and to teach

(Prideaux et al. 2000; Irby & Bowen 2004). Though all

doctors are usually well prepared for their clinical roles, few

are trained for their teaching roles (Steinert 2005). Clinical

teachers take their role as teachers of future generations of

doctors seriously and with enthusiasm. Yet, most lack

knowledge of educational principles and teaching strategies

thus may be inadequately prepared for this additional

professional role (Wilkerson & Irby 1998). It has simply

been assumed that professionals who have graduated

from medical schools/colleges and undergone

postgraduate training can automatically start teaching the

day after they graduate. Due to advances in education

such as new methods of teaching and learning, a

more student-centred teaching, competency based assess-

ment and emphasis on professionalism; educators today

are required to have an expanded toolkit of teaching skills

and clinical expertise (Harden & Crosby 2000; Searle et al.

2006).

Correspondence: Dr. Subha Ramani, Boston University School of Medicine, Boston, MA, USA. Tel: 1-617-638-7985; fax: 1-617-638-7905;

email: [email protected]

ISSN 0142–159X print/ISSN 1466–187X online/08/040347–18 � 2008 Informa UK Ltd. 347DOI: 10.1080/01421590802061613

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Clinical teaching overview

What makes a clinical teacher excellent?

Many investigators have examined the qualities that learners

value in their clinical teachers. Irby & Papadakis (2001)

summarized these and list the skills that make a clinical teacher

stand out (see Box 1).

Problems with clinical teaching

John Spencer has listed common problems with clinical

teaching in his article on learning and teaching in the clinical

environment published in the British Medical Journal’s ABC

of learning and teaching in medicine series (Spencer 2003).

The following are examples of such challenges, though by

no means a complete list:

. lack of clear objectives and expectations;

. teaching pitched at the wrong level;

. focus on recall of facts rather than problem solving;

. lack of active participation by learners;

. inadequate direct observation of learners and feedback;

. insufficient time for reflection and discussion;

. lack of congruence with the rest of the curriculum.

Challenges for teachers in the clinical environment

Teaching in the clinical environment comes with its own set

of unique challenges (Spencer 2003); some key ones are listed

in Box 2.

Despite the numerous challenges noted, many clinicians

find practical solutions to overcome them and excel in their

dual role as clinician and teacher. The remainder of this guide

focuses on practical educational strategies that clinicians can

use while teaching in the clinical environment from technical

skills to a scientific and professional approach to their

teaching.

General teaching models for teaching in anyclinical setting

Two models of clinical teaching have been successfully used

in faculty development of clinical teachers. Both models are

behaviour based and can be adapted by clinical teachers to all

clinical settings. The first is the Stanford Faculty Development

model for clinical teaching and the second is the Microskills

of teaching model, also known as the one-minute preceptor.

Practice points

. Clinicians do not become teachers by virtue of their

medical expertise, but a reflective approach to teaching

and professional development can foster excellence in

clinical teaching.

. By using an outcome based approach to teaching and

learning, clinical faculty can progress along the spectrum

of clinical teaching and if they choose to, they can

become truly professional teachers.

. Soliciting feedback on teaching and reflective practice

are key to advancing to the highest level of teaching and

moving from being a technically sound teacher to a

professional and scholarly teacher.

. Staff development can provide clinicians with new

knowledge and skills about teaching and learning. It

can also reinforce or alter attitudes or beliefs about

education.

. Staff development can provide a conceptual framework

for teaching and help clinical teachers adopt and adapt

specific teaching behaviours to real clinical settings and

introduce clinicians to a community of medical educa-

tors interested in furthering clinical teaching and

learning.

. Several models of teaching have been described in this

guide, they are behaviour based and can be easily

adapted to a 5-minute teaching encounter or a one-hour

encounter. These models could also help teachers set

defined objectives for each clinical teaching encounter

and also tailor objectives to individual learners.

. Clinical teachers should attempt to draw a road map of

their career as educators, what their ultimate goals are

(become technically proficient as teachers or researchers

and scholars or develop into educational leaders) and

how they intend to progress and accomplish their goals.

Box 2. Challenges of clinical teaching

. Time constraints

. Work demands – teachers maintain other clinical, research or

administrative responsibilities while being called upon to teach

. Often unpredictable and difficult to prepare for

. Engaging multiple levels of learners (students, house officers etc)

. Patient related challenges: short hospital stays; patients too sick or

unwilling to participate in a teaching encounter

. Lack of incentives and rewards for teaching

. Physical clinical environment not comfortable for teaching

From Focus group discussions of clinical faculty in the Department of

Medicine at Boston University School of Medicine

Box 1. Skills that make a clinical teacher excellent

Excellent clinical teachers:

. share a passion for teaching;

. are clear, organized, accessible, supportive and compassionate;

. are able to establish rapport; provide direction and feedback; exhibit

integrity and respect for others;

. demonstrate clinical competence;

. utilise planning and orienting strategies;

. possess a broad repertoire of teaching methods and scripts;

. engage in self-evaluation and reflection;

. draw upon multiple forms of knowledge, they target their teaching to

the learners’ level of knowledge.

S. Ramani & S. Leinster

348

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Stanford faculty development model forclinical teaching

A popular model for teaching improvement has been the

seven-category framework of analysis developed by the

Stanford Faculty Development Centre. This comprehensive

framework is outlined in the article by Skeff (1988). In

addition, this seven-category framework has been validated

by work at the University of Indiana which resulted in a 26

item questionnaire that can be used to evaluate teaching

(Litzelman et al. 1998). Although it provides a categorical

framework for evaluation and analysis of teaching, the power

of the model is most effectively demonstrated in hands-on

seminars in which faculty are enabled to both understand

and apply this method of analysis to their teaching. This

model described all clinical teaching as fitting into seven key

categories, lists key components under each category and

further describes specific teaching behaviours under each key

component.

The categories are as follows.

(1) Promoting a positive learning climate: The learning

climate is defined as the tone or atmosphere of the

teaching setting including whether it is stimulating, and

whether learners can comfortably identify and address

their limitations. It sets the stage for effective teaching

and learning.

(2) Control of session: This refers to the manner in which

the teaching interaction is focused and paced, as

influenced by the teacher’s leadership style. It reflects

the group dynamics, which affect the efficiency and

focus of each teaching interaction.

(3) Communication of goals: This includes establishment as

well as explicit expression of teachers’ and learners’

expectations for the learners. Setting goals provides a

structure for the teaching process, guides teachers in

planning the teaching and provide a basis for

assessment.

(4) Promoting understanding and retention: Understanding

is the ability to correctly analyse, synthesize and apply

whereas retention is the process of remembering facts

or concepts. This category deals with approaches

teachers can use to explain content being taught and

have learner meaningfully interact with the content,

enabling them to understand and retain it.

(5) Evaluation: It is the process by which the teacher

assesses the learner’s knowledge, skills and attitudes,

based on educational goals previously established. It

allows the teacher to know where the learner is and

helps them plan future teaching as well as assess

effectiveness of teaching. Evaluation can be formative

to assess ongoing learner’s progress towards educa-

tional goals or summative for final assessment to judge

learner’s achievement of goals.

(6) Feedback: Feedback is the process by which the

teacher provides learners with information about their

performance for potential improvement. It provides an

educational loop through which the teacher can guide

learners to use the evaluation of their performance to

reassess attainment of goals.

(7) Promoting self-directed learning: Teachers achieve this

by facilitating learning initiated by learner’s needs,

goals and interests. It stresses the importance of

acquiring skills to equip the learner to continue

learning beyond the time of formal education.

The one-minute preceptor

The ‘Microskills’ of teaching, also called the one minute

preceptor because of the short time available for teaching in

the clinical environment, provides a simple framework for

daily teaching during patient care (Neher et al. 1992). It is most

relevant to teaching postgraduate trainees but the steps also

apply to the longer encounters that are specifically focused on

teaching for undergraduates. These steps can be used to

structure effective short clinical teaching encounters that last

five minutes or less as well as to address problems that arise.

The original microskills model uses a five-step approach.

Step 1. Getting a commitment: The teacher encourages

learners to articulate their opinions on the differential

diagnosis and management rather than giving their own

conclusions and plans. The teacher must create a safe learning

environment so that learners feel safe enough to risk

a commitment – even if it is wrong.

Step 2. Probing for supporting evidence: The teacher

should encourage learners to ‘think out loud’ and give their

rationale for the commitment they have just made to diagnosis,

treatment, or other aspects of the patient’s problem. Teachers

should either validate learners’ commitments or reject them

gently if flawed.

Step 3. Teaching general rules: Teachers can guide learners

to understand how the learning from one patient can be

applied to other situations. The learner is primed for new

information they can apply to a given patient as well as future

patients. If the learner has performed well and the teacher has

nothing to add, this microskill can be skipped.

Step 4. Reinforcing what was done well: It is appropriate to

use this microskill every time the trainee has handled a patient

care situation well. Effective reinforcement should be specific

and behaviour based and not vague. Positive feedback also

builds the trainee’s self-esteem.

Step 5. Correcting mistakes: Negative or constructive

feedback is often avoided by clinical teachers, but this is

vital to ensure good patient care. Encouraging self-assessment

is a good way to have the learners realise their mistakes

themselves and if they have identified their errors, they can be

given positive feedback on their self-reflective capabilities.

If the teacher has to point out mistakes, this must be specific,

timely and based entirely behaviour based.

Applying the Dundee outcomesmodel in clinical teaching

It has been stated that the medical profession needs to think

more seriously about training their teachers and a framework

for developing excellence as a clinical educator is needed

(Hesketh et al. 2001). Harden et al. (1999) had previously

AMEE Guide no. 34: Teaching in the clinical environment

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proposed a 3-circle learning outcomes model to classify skills

and abilities that doctors must possess. The Dundee outcomes

model offers a user-friendly approach to communicate

learning outcomes and was adapted to describe outcomes

for medical teachers (Hesketh et al. 2001). We use this model

in describing outcomes expected of a clinical teacher, moving

from technical competencies to meta-competencies within

each circle (Figure 1).

(1) The inner circle refers to the fundamental tasks that

clinical teachers should be able to perform compe-

tently; doing the right thing.

(2) The middle circle represents the teacher’s approach to

clinical teaching with understanding and application of

relevant learning theories; doing the thing right.

(3) The outer circle represents the development of the

individual through a professional approach to teaching

in the clinical environment; the right person doing it.

In applying the three-circle outcomes model for teachers in

the clinical environment we have attempted to keep these

outcomes clear and unambiguous, specific, manageable

and defined at an appropriate level of generality (Harden

et al. 1999) (see Box 3).

Circle one: what the clinicalteacher should be able to do(doing the right thing)

We list the following tasks as essential for teachers in

the clinical environment: time efficient teaching, inpatient

teaching, outpatient teaching, bedside teaching, assessment

of learners in the work setting and giving feedback.

Time efficient teaching

Irby & Bowen (2004) described a 3-step approach for time

efficient teaching in the clinical environment. All three steps

described can be adapted equally well to a one-hour session

as a 10-minute teaching session.

Planning. Advanced planning can achieve the following:

. sharpen expectations;

. clarify roles and responsibilities;

. allocate time for instruction and feedback;

. focus learners on important priorities and tasks.

The planning stage includes communicating expectations to

learners, soliciting learners’ goals, creating a safe and

respectful learning environment, selecting appropriate patients

for the teaching and priming learners about the goals of the

session.

Teaching. Distinguished clinical teachers draw upon a

repertoire of teaching strategies to meet the needs of their

learners and selectively use any or all of the following five

common teaching methods.

. Teaching from clinical cases; combining simple discussions

for novice learners with higher level discussions for more

senior learners

The clinicianas aprofessionalteacher

The clinicalteacher’sapproach toteaching

The basictasks aclinicalteacher mustperform

Adapted from Harden et al. 1999

Figure 1. The Dundee 3-circle outcomes model.

Box 3. Applying the three-circle outcomes model for teachers in the clinical environment

Tasks of a clinical teacher (Doing the right thing) Approach to teaching (Doing the thing right) Teacher as a professional (The right person

doing it)

. Time efficient teaching . Showing enthusiasm for teaching and

towards learners

. Soliciting feedback on teaching

. Inpatient teaching . Understanding learning principles relevant to

clinical teaching

. Self-reflection on teaching strengths and

weaknesses

. Outpatient teaching . Using appropriate teaching strategies for

different levels of learners

. Seeking professional development in

teaching

. Teaching at the bedside . Knowing and applying principles of effective

feedback

. Mentoring and seeking mentoring

. Work based assessment of learners in

clinical settings

. Modelling good, professional behaviour

including evidence based patient care

. Engaging in educational scholarship

. Providing feedback . Grasping the unexpected teaching moment

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. Using questions to diagnose not only learners’ capacity for

recall but also their analysis, synthesis and application

capabilities

. Using advanced learners to participate in the teaching

. Using illness and teaching scripts. Examples of illness scripts

include knowledge of typical symptoms and physical

findings, predisposing factors that place the patient at

risk and underlying pathophysiology. Teaching scripts

commonly include: key points with illustrations, apprecia-

tion of common errors of learners and effective ways of

creating frameworks for beginners to build their own ‘illness

scripts’.

. Acting as role-models at the bedside or in examination

rooms

Evaluating and reflecting. Observing learners directly is an

important prerequisite for effective feedback. Feedback

should be based on observed behaviours, include positive

and negative feedback and teachers need to promote self-

assessment by learners. These techniques are discussed

in greater depth later.

Inpatient teaching

Ende (1997) wrote that the role of the inpatient teacher is one

of the most challenging in medical education, that of a master,

mentor, supervisor, facilitator, or all of the above. Inpatient

teaching can be chaotic and frustrating, as students of varying

levels of sophistication and interest fight off (or surrender to)

interruptions and urges to sleep, while the attending physician

holds forth on unanticipated topics, and about patients

who may not be available. Despite the various challenges

(see Box 4), he states that inpatient teaching can be riveting

if the teachers follow some basic principles. Teachers should

try to facilitate knowledge acquisition by asking questions that

make learners think and reason rather than recall facts. More

importantly, knowledge should be applied to specific patients

for clinical problem solving. Teachers should have some

knowledge of different learning styles and adapt their teaching

style to different learners. Teachers can set a comfortable and

safe learning environment in which they and the learners

freely ask questions and are prepared to admit their limitations.

Inpatient teams also need to behave as a teaching community

where each member respects the other in order to maximize

their learning. Teachers should learn to challenge their

learners without humiliating them and provide support so

that learning can be furthered. Ende suggests that in

preparation for effective ward teaching, the teachers should

ask themselves a set of questions before each teaching

encounter.

(1) What do you hope to accomplish?

(2) What is your point of view?

(3) How will your learners be engaged?

(4) How will you meet the needs of each learner?

(5) How will rounds be organized?

(6) Are your rounds successful?

(7) How will you make the time?

Although these questions can be applied to any clinical

environment, they are particularly apt for the inpatient

setting where a little mental preparation goes a long way.

Time constraints, varying learner levels, unexpected teaching

moments, presence or absence of the patient can all be

factored in while the teacher attempts to answer these

questions.

Outpatient teaching

Clinical teaching has recently been moving from the wards to

clinics. In recent years, the outpatient clinics have become an

integral venue to teach clinical medicine. With shorter hospital

stays, it has become impossible for trainees to follow and learn

the natural history of a disease from the inpatient environment.

Outpatient settings provide one area where trainees can learn

this, follow the patient over time and become involved in the

psychosocial aspects of patient care (McGee & Irby 1997;

Prideaux et al. 2000). Outpatient clinics are exceedingly busy

and chaotic settings with very short teacher-trainee interactions

(see Box 5). Often, clinical teachers are providing direct

Box 5. Challenges of outpatient teaching

. Busy clinical setting

. Teaching time often short, no time for elaborate teaching

. No control over distribution and organization of time

. Attending to several patients at the same time with multiple learners

. Brief teacher-trainee interactions

. Patient care demands usually take priority and must be addressed

. Multiple patient problems must be addressed simultaneously, so

teachers cannot focus on one problem to teach

. Learning and service take place concurrently

. Organic and psychosocial problems are intertwined

. Diagnostic questions often settled by follow up of empiric treatment

. Teacher should be a guide and facilitator than information provider

Box 4. Challenges of inpatient teaching

1. Difficult to set teaching goals, unanticipated events occur frequently

2. Ward team usually composed of varying levels of learners

3. Patients too sick or unwilling to participate in the teaching encounter

4. Patient stays are too short to follow natural history of disease

5. Teachers could compromise trainee-patient relationship if they

dominate the encounter

6. Trainees and teachers feel insecure about admitting errors in front of

the patient and the rest of the medical team

7. Tendency by many clinical teachers to lecture rather than practise

interactive teaching

8. Engaging all learners simultaneously can be difficult

9. Teachers need to pay close attention to learner fatigue, boredom

and workload

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patient care while supervising and trying to teach students and

residents (Neher et al. 1992; McGee & Irby 1997). In a busy

clinic, patients too may not be interested in being participants

of a trainee-teaching encounter. Overall, service requirements

outweigh teaching requirements thus making this an uncon-

trolled teaching setting. Techniques originally described for

effective inpatient teaching do not apply well to outpatient

teaching. The outpatient clinic promises many unique educa-

tional opportunities including more complete observation

of chronic diseases, closer relationships between teachers

and learners, and a more appropriate forum for teaching

preventive medicine, medical interviewing, and psychosocial

aspects of disease (McGee & Irby 1997).

McGee and Irby describe practical tips for efficient teaching

in the outpatient settings and they categorize these steps

as follows.

(1) Prepare for the visit: Orientate learners of the

number of patients to be seen, time to be spent with

each patient and how to present patients succinctly.

(2) Teach during the visit: Ask questions to diagnose the

learner’s knowledge and clinical reasoning, select

a specific teaching point in each case, model good

physician-patient interactions, observe at least in part

learner-patient interactions and provide timely and

specific feedback.

(3) Teach after the visit: Answer questions that arise from

specific patient problems, clarify what learners did not

understand, refer to literature and create reading

assignments.

Wolpaw et al. (2003) describe a model for learner-centred

outpatient precepting where learners are equal if not

the leaders of the teaching interaction. They applied the

mnemonic SNAPPS to this model. The six steps of the SNAPPS

model are described below.

(1) Summarize briefly history and exam findings:

The learner obtains a history, performs an appropriate

examination of a patient, and presents a concise

summary to the supervisor. The summary should

be condensed to relevant information because the

preceptor can readily elicit further details if needed.

(2) Narrow the differential diagnosis: For a new patient

encounter, the learner may present two or three

reasonable diagnostic possibilities. For follow-up or

sick visits, the differential may focus on why

the patient’s disease is active, what therapeutic inter-

ventions might be considered, or relevant preventive

health strategies.

(3) Analyse the differential diagnosis: In this step, the

learner should compare and contrast diagnostic possi-

bilities with evidence of clinical reasoning.

This discussion allows the learner to verbalize his or

her thinking process and can stimulate an interactive

discussion with the preceptor. This discussion also

helps clinical teachers to diagnose the level of their

learners and thus plan further teaching accordingly.

(4) Probe the preceptor by asking questions about

uncertainties, difficulties, or alternative approaches.

This step is the most unique aspect of the learner-

driven model because the learner initiates an educa-

tional discussion by probing the preceptor with

questions rather than waiting for the preceptor to

initiate the probing of the learner. The learner is taught

to utilize the preceptor as a knowledge resource that

can readily be accessed.

(5) Plan management for the patient’s medical issues.

The learner initiates a discussion of patient manage-

ment with the preceptor and must attempt either a brief

management plan or suggest specific interventions.

This step asks for a commitment from the learner,

but encourages him or her to access the preceptor

readily as a rich resource of knowledge and

experience.

(6) Select a case-related issue for self-directed learning.

The learner may identify a learning issue at the end of

the patient presentation or after seeing the patient with

the preceptor. The learner should check with the

preceptor to focus the reading and frame relevant

questions.

Teaching at the bedside

It has been stated that since clinical practice involves the

diagnosis and management of problems in patients, teaching

of clinical medicine should be carried out on real patients with

real problems (Nair et al. 1997). There are many skills that

cannot be taught in a classroom, particularly the humanistic

aspects of medicine (Nair et al. 1997; Ramani 2003)

and require the presence of a patient, real or simulated. The

patient’s bedside, however, appears to be one of the most

challenging settings for clinical teachers. Although many

clinical teachers find this an intimidating mode of teaching

that bares their own deficiencies, they need to realize that all of

them possess a wide range of clinical skills that they can teach

their junior and far less experienced trainees (Ramani et al.

2003). Some common sense strategies combined with faculty

development programmes at individual institutions can over-

come some of this insecurity and promote bedside rounds,

which can be educational and fun for teachers and learners

alike. Teachers’ insecurities can be classified into 2 major

domains (Kroenke 2001):

. Clinical domain: Teachers may feel insecure about their

knowledge being up to date.

. Teaching domain: Teachers often feel intimidated by having

to teach a heterogeneous group of learners who are busy

and frequently sleep deprived.

Twelve practical tips have been described to help ease teacher

discomfort at the bedside and promote effective bedside

teaching (Ramani 2003).

(1) Preparation: Teachers need to familiarise themselves

with the clinical curriculum, attempt to diagnose

different learner levels and improve their own clinical

skills.

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(2) Planning: Ende (1997) suggests that all clinical

teachers should ask themselves the following questions

prior to a teaching encounter and try to answer them:

a. What do you hope to accomplish?

b. What is your point of view?

c. How will your learners be engaged?

d. How will you meet the needs of each learner?

e. How will rounds be organized?

f. Are your rounds successful?

g. How will you make the time?

(3) Orientation: Teachers should obtain objectives of

learners, assign roles to each of the team members, try

to engage everyone and establish team ground rules.

(4) Introduction: The team of doctors need to be intro-

duced to patients and patients should be oriented about

the nature of the bedside encounter; e.g. Patients need

to be told that the encounter is primarily intended for

teaching and that certain theoretical discussions may

not be applicable to their illness.

(5) Interaction: The clinical teachers should serve as role-

models during their physician-patient interactions and

teach professionalism and a humanistic bedside

manner. In addition, teachers should model team

work and promote positive team interactions including

professional interactions with nursing and other ancil-

lary staff.

(6) Observation: Teachers need not put on a show at the

bedside and dominate the bedside encounter (Kroenke

2001). Observing the trainees’ interaction with the

patient at the bedside can be very illuminating and

these observations can be used to plan future teaching

rounds.

(7) Instruction: Clinical teachers should avoid asking the

trainees impossible questions and ‘read my mind’ types

of questions (LaCombe 1997; Kroenke 2001) and

actively discourage one-upmanship among learners.

Admitting one’s own lack of knowledge might allow

trainees to admit their limitations and ask questions.

Teachers can role model their willingness to learn by

being prepared to learn from trainees.

(8) Summarise: Learners would find it beneficial if teachers

summarize what was taught during that encounter.

Patients also need a summary of the discussion, what

applies and what does not apply to their illness and

management.

(9) Debriefing: Time is needed for learners to ask questions

and teachers to make clarifications and assign further

readings.

(10) Feedback: Teachers can find out from learners what

went well and what did not and give positive and

constructive feedback to learners.

(11) Reflection: Reflections about the bedside encounter

coupled with learner feedback can help teachers plan

the next encounter.

(12) Preparation for the next encounter should begin with

insights from the reflection phase.

Work based assessment of learners in theclinical cenvironment

Assessment plays a major role in the process of medical

education, in the lives of medical students, and in society by

certifying competent physicians who can take care of the

public. Society has the right to know that physicians who

graduate from medical school and subsequent residency-

training programmes are competent and can practise their

profession in a compassionate and skilful manner (Shumway

& Harden 2003). Miller (1990) proposed his now famous

pyramid for assessment of learners’ clinical competence

(Figure 2). At the lowest level of the pyramid is knowledge

Adapted from Miller (1990)

Knows

Application of knowledge:tested by clinical problemsolving etc

Knowledge: testedby written exams

Knows how

Shows how

Does

Demonstration of clinicalskills: tested by OSCE, clinicalexams etc (competency)

Daily patient care:assessed by directobservation in clinicalsettings (Performance)

Figure 2. Miller’s pyramid of assessment.

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(knows), followed by competence (knows how), performance

(shows how), and action (does) The clinical environment is

the only venue where the highest level of the pyramid can be

regularly assessed.

Studies have indicated that performance in high stakes

examinations do not accurately reflect what doctors do in

actual patient care (Ram et al. 1999; Rethans et al. 2002).

Patient outcomes are the best measures of quality to assess

learners in the clinical settings (Norcini 2003), but these are

often difficult to ascertain due to factors such as case mix, case

complexity, nature of the clinical team and other intangible

factors. Assessment in the workplace is quite challenging as

patient care takes top priority and teachers have to observe

firsthand what the learners do in their interaction with patients

and yet be vigilant that patient care is of the highest quality.

Performance outcomes. Norcini (2003) states that the princi-

pal measures of performance in the clinical environment

include patient outcomes, process of care and volume of

services doctors provide.

. Patient care outcomes include morbidity and mortality,

physiological outcomes such as blood pressure or diabetes

control, clinical events such as stroke or heart attack and last

but not least patient satisfaction and experience with care.

. Process of care includes such factors as patient screening,

preventive services provided, disease specific measures

such as HbA1C for diabetes, aspirin prescription after a

heart attack etc.

. Patient volume refers to features such as number of hip

replacements performed by orthopaedic surgeons or

cardiac catheterizations performed by cardiologists.

Volume, in general, correlates with skill and patient

morbidity and mortality, but does not always equal high

quality patient care.

Clinical teachers should gain familiarity with an outcomes

based assessment method appropriate to their own environ-

ment (CANMEDS, ACGME, LCME etc.).

Rethans et al. (2002) emphasize that the distinction

between competency-based and performance-based methods

is important and propose a new model, designated the

Cambridge Model, which extends and refines Miller’s pyramid.

It inverts his pyramid, focuses exclusively on the top two tiers,

and identifies performance as a product of competence, the

influences of the individual (e.g. health, relationships), and

the influences of the system (e.g. facilities, practice time). The

model provides a basis for understanding and designing

assessments of practice performance.

Assessment methods. In the clinical environment, faculty can

readily assess any of the performance measures described

above that relate directly to patient care. In these settings,

trainees’ clinical skills can be assessed outside a simulated or

test environment; skills such as patient communication,

physical examination, clinical reasoning, case presentation

and notes, team work, communication with clinical and non-

clinical staff and professionalism. Methods of assessment

include examining case records and notes for evidence of

diagnostic thinking, listening to case presentations, but the

most important method of assessment for clinical teachers

would be direct observation. Without observing trainees at

work and at the bedside, teachers cannot gather accurate data

to provide appropriate feedback.

Giving feedback

In the clinical environment it is vital to provide feedback to

trainees as without feedback their strengths cannot be

reinforced nor can their errors be corrected (Ende 1983). It is

a crucial step in the acquisition of clinical skills, but clinical

teachers either omit to give feedback altogether or the quality

of their feedback does not enlighten the trainees of their

strengths and weaknesses. Omission of feedback can result in

adverse consequences, some of which can be long term

especially relating to patient care. For effective feedback,

teachers need to observe their trainees during their patient

interactions and not base their words on hearsay. Feedback

can be formal or informal, brief and immediate or long and

scheduled, formative during the course of the rotation or

summative at the end of a rotation (Branch & Paranjape 2002).

Why is feedback needed? Feedback is essential for a student

or intern to gain an insight into what they did well or poorly

and the consequences of those actions. If educational goals

had been established ahead of the teaching encounter or

period, feedback is essential to examine accomplishment or

lack thereof of stated goals, re-establish new goals and make

action plans to address them (Ende 1983). It tells the learners

where they are in comparison to where they ought to be and

where they should go. Feedback, when well done, also

promotes self-reflection and self-assessment, which are valu-

able traits for lifelong learning.

Barriers to feedback. One of the biggest hurdles to giving

feedback is lack of direct observation of trainees by teachers

(Ende 1983). Clinical competence cannot be assessed by

written exams, self-report or third party observation, rather this

needs to be observed directly by clinical teachers. Teachers are

also very hesitant to provide negative feedback and frequently

avoid it altogether although this can have adverse conse-

quences on patient care. Trainees, on the other hand, may

view negative feedback as a personal attack. Teachers need to

establish a positive learning environment in which errors are

acknowledged and feedback is expected and accepted.

Frequently, feedback is non-specific and unhelpful to learners,

e.g. ‘good job’, ‘bad patient communication’, etc.

Circle 2: how the clinical teacherapproaches their teaching(doing the thing right)

Showing enthusiasm for teaching andtowards learners

The starting point for any good teacher must be enthusiasm for

the subject being taught. This has to be complemented by

an eagerness to transmit this enthusiasm to others, which

will necessarily result in a positive attitude to learners.

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Enthusiasm for the subject is usually accompanied by a sound

knowledge of the subject and a desire to learn more about it,

both of which are pre-requisite for successful teaching in

higher education. However, while enthusiasm, knowledge and

a desire to learn more are necessary for successful teaching

they are not sufficient. Teaching is a professional discipline

with its own theoretical background and its own recognised

techniques. A good teacher must have and apply a working

knowledge of both techniques.

Understanding learning principles relevantto clinical teaching

Pedagogy versus androgogy. Much of our approach to

teaching and learning is based on studies in children at

school and is therefore termed pedagogy. The content of

learning is defined by a syllabus and the method of learning is

laid down by a curriculum. Both of these may be developed

by the individual teacher but are likely to have been laid

down by a central authority. The pace of learning is dictated

by the teacher. Knowles (1990) studied adults enrolled

at evening classes in New York and realised that their

approach to learning was different. He coined the term

androgogy to cover this approach. The content of the

student’s studies is dictated by perceived need; the method

of learning is selected by the learner and the pace of learning is

dictated by the learner. From his observations Knowles

derived a set of Principles of Adult Learning which are now

widely regarded as crucial to the design of any course for

adults (Box 6).

Learning theories. Theories of learning may be neurobiolo-

gical or behavioural. From a pragmatic educational viewpoint

the most useful at present are the behavioural theories. These

can be broadly classified as individualistic (based on

psychological approaches) and social constructivist (based

on sociological approaches). While some of the proponents of

each theory will claim that their insights are the only valid

approach, the practical educator can draw lessons from all of

them. It is important to recognise that the theories are

attempting to describe what actually occurs in learning rather

than what ought to occur.

Psychological theories. Learning and memory. There is an

extensive literature on learning and memory. There appears to

be a consensus that different models apply for the learning of

knowledge and the acquisition of skills. Clinical teaching must

deliver both modalities.

The first stage of acquiring knowledge is the activation of

prior knowledge. This is followed by the acquisition of new

knowledge. The new knowledge is incorporated into the

memory through rehearsal which is more effective if it is done

to a third party. The final stage of the learning process is

elaboration. This may take the form of transforming the

information into a different format e.g. summarizing words as a

chart or diagram; comparing and contrasting new information

with old; or drawing inferences and conclusions from the total

information (Bransford et al. 1999). A slightly different

articulation of this process is Schmidt’s Information

Processing Theory which emphasises the link between the

remembering of the new material and the prior knowledge

that has been activated which he describes as encoding

specificity (Schmidt 1983).

The commonest model used to describe the acquisition of

skills is the conscious-competence model. This model is

widely used in management training but no-one is entirely

clear where it originated. Four stages of ability are described,

as described in Box 7.

A fifth stage has been suggested which can be thought of as

reflective competence. It is often the case that the person who

is operating at the level of unconscious competence is unable

to teach others the skill. The person who has reflective

competence is able to perform the task without conscious

thought but can if necessary analyse what they are doing in

order to teach the skill to someone else (Chapman 2007).

Self-determination theory. It is self-evident that students’

learning is affected by their motivation. Williams et al. (1999)

suggest that the nature of the motivation is important.

According to self-determination theory there are two primary

kinds of motivation – controlled and autonomous. Controlled

motivation is brought about by external pressures (other

people’s expectations; rewards and punishments) or by

internalized beliefs about what is expected. In contrast,

autonomous motivation occurs when individuals see the

material to be learnt as intrinsically interesting or important.

Controlled motivation leads to rote-learning with little

Box 6. Principles of adult learning

Adults:

. have a specific purpose in mind;

. are voluntary participants in learning;

. require meaning and relevance;

. require active involvement in learning;

. need clear goals and objectives;

. need feedback;

. need to be reflective.

Knowles (1990)

Box 7. The conscious-competence model

Unconscious incompetence The subject is not aware of the skill in

question

Conscious incompetence The subject is aware of the skill and

recognizes the need to acquire it

Conscious competence The subject has acquired the skill but

needs to focus their attention on its

performance

Unconscious competence The subject has achieved mastery of the

skill and can perform it without

conscious thought; other tasks can

be performed at the same time.

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integration of the material into the student’s long term values.

Autonomous motivation, among other benefits, leads to

greater understanding, better performance, and greater feel-

ings of competence. In addition, students who are encouraged

to develop an autonomous approach to learning are more

likely to act in ways that promote the autonomy of their

patients.

Experiential learning. Most informal learning is based on

experience. Kolb (1984) described the process by which this

occurs in his learning cycle. Learning occurs when an

individual reflects on an experience. On the basis of this

reflection, the individual will develop a working theory

(although they may not fully articulate it), which will lead

them to take a certain course of action. That action will result

in a further experience and so the cycle continues with a

steady accumulation of useful knowledge. The cycle can be

entered at any point. For example, an individual may be told

about a theory and take action without having had previous

experience of the particular situation. Different individuals will

have different preferences for the starting point depending on

their learning style (see below).

Sociological theories. Situated learning. Vygotsky, the

Russian educational psychologist, postulated on the basis of

his study of school children that learning was socially

determined and resulted from the interaction of the child

with those around her. He observed that if a child has adult or

peer support she can solve problems that she is incapable of

solving unaided. This difference between aided and unaided

performance he called the zone of proximal development and

suggested that it is here that learning takes place. In other

words, interaction with others is essential to learning

(Vygotsky 1978).

Communities of Practice. Clinical activity usually takes place

in teams. Such teams are important not only for the delivery of

care but for the continuing professional development of the

team members. Functional teams form communities of practice

in which the individual members support one another. It is a

feature of such groups that knowledge and skills are rapidly

disseminated throughout the group. This may be through

formal structures such as seminars but is more likely to be

through the informal day-to-day contact between members.

Lave & Wegner (1991) suggest that learners or apprentices are

legitimate peripheral participants in such groups. Although

they have yet to achieve full membership of the group they are

allowed to take part in the activities of the group and in that

way they also acquire the knowledge that is inherent in the

group. Eventually, they will be absorbed into the group and

accepted as a full member of the group. This transition is often

marked by ceremony such as passing the final examination.

Reflective practice. At first sight, reflective practice might

seem to be an individualistic learning method rather than a

social one. However, Schon (1995) identified that reflection is

much more effective when conducted with a mentor making it

a social activity. He describes two forms of reflection:

reflection in action which takes place during an activity,

and reflection on action which takes place once that action has

been completed. Both are important adjuncts to learning.

Learning styles. It is apparent that different individuals have

different approaches to learning. There have been a variety of

attempts to describe these different approaches or learning

style. Some classifications focus on the cognitive aspects of

learning; some focus on the modalities of learning preferred by

the learners; a third group focus on the outcomes of the

learning.

Cognitive approach – Honey and Mumford Learning Style

Inventory. The Honey and Mumford Learning Style

Inventory is widely used in management training. It is based

on Kolb’s learning cycle and identifies four main learning

styles (Honey & Mumford 1992).

. Pragmatists prefer to learn directly from experience

. Reflectors prefer to learn by reflecting on their experiences

. Theorists prefer to learn by developing explanations and

working theories

. Activists prefer to learn by involvement in activity.

No individual has a single preferred style of learning but each

individual will display the learning styles to differing degrees.

Modalities of learning – visual–auditory–kinaesthetic learning

style. A potentially more useful learning style questionnaire is

the visual–auditory–kinaesthetic (VAK) questionnaire which is

widely used in schools. The emphasis is on the subject’s

preferred modality for acquiring material to be learnt.

. Visual learners prefer material that is delivered through

visual media. This includes written and graphic material but

also electronic visual media.

. Auditory learners prefer the spoken word to visual material.

. Kinaesthetic learners learn best when the learning involves

them in physical activity.

Learners will usually display a mixture of the three learning

styles although one may predominate.

Outcomes of learning – deep/superficial learning. The

desired goal for learning is that the learners should achieve

understanding of the subject. This is called deep learning.

When the amount of material to be learnt is too great, or where

the assessment of the learning is based purely on recall,

learners will display superficial learning. Experienced students

will identify those aspects of the material presented which

need to be understood for future use and those which will

merely need to be recalled for the purposes of assessment.

They will adopt a deep learning approach for the former and a

superficial learning approach for the latter. This combined

approach is described as strategic learning (Newble &

Entwhistle 1986).

The teacher’s goal must be to develop deep learning.

Because students have differing patterns of learning styles,

the material to be learnt must be presented in a variety of

ways. Patient-centred teaching involves all modalities of the

VAK approach as the student will observe the patient, hold

conversations with the patient and the instructor and will

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carry out physical activity in examining the patient and

carrying out clinical procedures. It is also evident that

patient-centred teaching will give the student experiences

as a result of activities that they undertake. The teacher

needs to encourage reflection on what has taken place

linked to a discussion of the theoretical background to the

case.

Using appropriate learning strategies for differentlevels of learner

Approaches to teaching in the clinical setting will differ

according to the level of the students being taught.

Undergraduates are likely to be taught in sessions specifically

dedicated to this end. Postgraduate trainees may well be

taught in the course of routine service delivery. In any clinical

teaching session it is important that the teacher has clear goals

and objectives for the session. If the teacher is unsure what

they are trying to achieve, the students will not be able to

identify the purpose of the session. This will conflict with the

principles of adult learning.

Motivation is rarely a problem with students in the clinical

setting. Failure to engage with the student is more likely to be a

result of poorly constructed teaching sessions rather than

student motivation. This is often due to the selection of

inappropriate goals for the session.

The purpose of the session will differ depending on the

level of the student. The underlying teaching methods can be

the same. The new undergraduate who is developing the art of

history taking will require different goals from the senior

postgraduate student who is learning the nuances of managing

variants of the same disease. Both can be taught on the same

patient by focusing on different learning tasks. It is not a good

idea to try to teach both at the same time as they have different

goals and objectives.

The session should start with establishing what the student

already knows relevant to the patient’s presentation and this

should include their understanding of the scientific back-

ground as well as the clinical aspects. Failure to establish the

students starting point is another common reason for the

failure of the student to engage in a teaching session. The topic

chosen by the teacher may be too advanced or too elementary

for the group of students being taught. In either case the

student will have difficulties.

The students should be active participants in the session.

Merely telling the students the teacher’s view of the situation

or having them observe the expert in action does not lead

to deep learning. The students should be permitted to carry

out relevant components of the clinical task and then be

engaged in active discussion. In this way the full range of

different learning styles can be accommodated. Dialogue

with the student is an important part of clinical teaching.

Attention should be paid to probing the students’ under-

standing rather than their simple ability to carry out a

mechanical task or recall isolated facts. The questions ‘Why’

and ‘So what’ are an essential part of the clinical teachers

armamentarium. This will encourage the elaboration stage of

learning.

Knowing and applying principles of giving feedback

Feedback should provide the student with the opportunity to

reflect on their performance and its possible consequences. It

can guide the student’s future learning by identifying their

strengths and weaknesses (Sender Liberman et al. 2005). The

principles of giving feedback have been well-rehearsed by a

number of authors. These principles include the use of

mutually agreed upon goals as a guide to the feedback;

addressing specific behaviours not general performance;

reporting on decisions and actions not on one’s interpretation

of the student’s motives; and using language that is non-

evaluative and non-judgemental (Ende 1983). These attri-

butes have been found empirically to be valued by trainees

(Hewson & Little 1998). Feedback may be corrective (when

the student’s performance has been inadequate) or reinfor-

cing (well the student has done well) (Branch & Paranjape

2002). Feedback may be formal or informal. In the clinical

teaching setting timely, informal feedback is highly valued by

the students.

The first requirement of feedback is that the student has a

clear concept of the objective they are trying to attain.

Feedback can then inform how close they have come to

achieving that target and ideally what they need to do

differently in order to achieve the target. Direct observation

of the performance is necessary if feedback is to be effective.

The objective may be a behaviour such as a clinical skill or a

cognitive process such as interpreting a history.

At the simplest level feedback informs the student that

they have either succeeded or failed at the task. This is

common in licensing examinations where the candidate

knows either that they have passed or failed but is not told

why. In the clinical setting it would be more usual for the

student to be told that their performance was inadequate and

then a demonstration given of how it should have been

done. Once again the student is not offered an analysis of

what they did wrong. This approach does not provide the

best opportunity for the student to learn and is more akin to

evaluation than feedback.

Learning is assisted when both the strengths and the

weaknesses of the student’s performance are identified and

discussed. Feedback is not evaluation and therefore should not

use judgemental language or make personal remarks. The

emphasis should be on reporting the observed behaviours and

thinking and should be detailed and specific rather than

general. It is a good technique to start with self-assessment as

many astute learners usually identify their errors and the

teacher can help make plans to correct those errors and

reinforce their strengths. It is often the case that the student’s

judgement of their performance is harsher than the teacher’s

and it is important to reassure the student that they have done

well.

Clinical learning often takes place in a group environment.

In this setting it is helpful to involve the other members of the

group in the informal feedback process. They often have

valuable insights into why their colleague behaved as she did

and, in addition, they will learn the process of constructive

feedback. More formal summative feedback should be given

in private at a mutually agreed time.

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Above all feedback should be constructive. This does not

mean that the student’s performance cannot be criticized but

when there are deficiencies the feedback should include

suggestions for making improvements.

Role modelling

An important part of clinical reaching is the development of

the professional role in the students. Both trainees (Brownell &

Cote 2001) and faculty (Wright & Carrese 2002) agree that the

observation of role models is the most important component in

this process. This fits well with the theories of situated learning

and communities of practise discussed previously. If positive

messages are to be transmitted consistently it is essential that

teachers reflect on their own attitudes and behaviours (Kenny

& Mann 2003). Modelling life long learning requires that the

teacher is willing to admit ignorance and prepared to learn

from the students. Good doctor-patient relationships and

evidence based clinical practice are other areas where the

teacher’s behaviour will reinforce (or undesirably contradict)

their formal teaching.

‘Grasping the unexpected teaching moment’

Unpredictability is one of the attractions of clinical practice.

There are occasions when it is better to abandon the carefully

constructed teaching plan and seize the opportunity which

suddenly presents itself. After all, the unexpected will be what

excites you and you are likely to transmit that excitement to

the students. A sound grasp of the theoretical approaches to

teaching are no substitute for enthusiasm for the process of

teaching and for the subject that is being taught.

A key prerequisite for using the unexpected teaching

moment most efficiently is a teacher’s willingness to admit

their errors or limitations, thus allowing learners to admit their

own without an a climate of humiliation.

Circle 3: the clinician as aprofessional teacher (the rightperson doing it)

Even if a teacher can master all the technical competencies

listed in the inner circle, emotional and attitudinal

competencies such as self-awareness, self-regulation, motiva-

tion, empathy and social skills are required to achieve

excellence (Harden et al. 1999).

We list the following as essential circle 3 tasks for

clinical teachers by which they may become the ‘right persons

doing it’.

. Soliciting feedback on teaching

. Self-reflection

. Professional development in teaching

. Mentoring.

Soliciting feedback on teaching

Most clinical teachers go about their business of teaching with

very little feedback on their strengths and weaknesses as a

teacher. Frequently, the only evaluations on their teaching are

from learners and these too may be few and far between.

Some institutions have adopted a coaching or consulting

service for teachers, but these pertain more to classroom

teaching or small group teaching rather than teaching in the

clinical environment. More institutions should adopt a 360-

degree method for evaluating their clinical teachers rather than

depend on incomplete and ineffective evaluations from

learners alone. These may include measures such as learners’

performance and progress as a proxy for teaching impact,

video recording of teaching sessions with reflection and

feedback, teacher self reports, peer observations etc.

In the face of overwhelming expectations at work, clinical

faculty rarely ask for feedback on their teaching from learners

or peers. The clinical environment adds an additional twist by

the all-important focus on patient care and safety. Thus,

frequently the emphasis is on the patient and their manage-

ment and the teaching strategies are all but forgotten. In the

event that a teacher asks their learners for feedback, learners

hesitate to offer it as there may be some anxiety about their

own evaluations by their teachers. Those learners that offer

feedback give non-specific, vague feedback that teachers

cannot readily assimilate or apply in their future teaching

encounters.

Teachers should be encouraged to seek feedback on their

teaching from peers and learners, staff development should

train teachers in efficiently obtaining feedback and last but not

least a teaching consulting or coaching service developed by

institutions for clinical teachers would help improve teaching

skills of individual teachers as well as the institution as

a whole. Trainees too can benefit from coaching and

encouragement on providing useful feedback to their teachers.

Self-reflection

Reflection in medicine has been defined as consideration of

the larger context, the meaning, and the implications of an

experience or action (Branch & Paranjape 2002) and when

used properly allows for the growth of the individual. It has

also been stated that professionals must distinguish themselves

from technicians by awareness of the larger context of their

work using this knowledge for lifelong learning and not

limiting themselves to performing specific tasks (Schon 1987;

1983). One might therefore assume that reflection, so essential

to educating physicians, is even more crucial for clinical

teachers to adopt a professional approach to their teaching,

namely be the right person doing it.

Both phases of reflective practice (Kaufman 2003), reflec-

tion in action which occurs immediately and reflection on

action which occurs later, are readily applicable to clinical

teachers.

Fryer-Edwards et al. (2006) have suggested three key

teaching skills that illustrate learner-centred, reflective

teaching practices and provide a framework for teachers

with both cognitive and affective components. Although

these teaching practices were developed for communication

skills training, they are readily applicable to any clinical

environment.

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. Identifying a learning edge: Teachers work with learners to

identify their learning edge, which is the place where they

find learning challenging, but not overwhelming.

. Proposing and testing hypotheses: Teachers formulate

hypotheses on issues such as barriers or facilitators to

learning for individual learners, learning needs, emotional

responses to patients or the rest of the team and apply

teaching strategies to test these hypotheses.

. Calibrating learners’ self-assessments: This involved

learners thinking out aloud their self-assessment, values

and beliefs and using these insights to stimulate further

reflection.

Professional development

Medical education has traditionally had little input from trained

educators. In the past, a high level of clinical competence and

experience was considered sufficient to be a good clinician

educator, now it is increasingly recognized that teaching itself

is a skilled profession. The British General Medical Council in

its publication: Tomorrow’s Doctors, includes the following

attributes of a practitioner (General Medical Council 2002).

. Recognition of the obligation to teach others, particularly

doctors in training.

. Recognition that teaching skills are not necessarily innate

but can be learned.

. Recognition that the example of the teacher is the most

powerful influence upon the standards of conduct and

practice of trainees.

Most clinical faculty receive little or no explicit training in how

to teach, or in theories and processes of teaching. Yet, they are

expected to help their trainees master medical knowledge,

clinical skills and acquire a habit of lifelong learning. In the

changing world of medicine, clinical teachers need to perform

time-efficient ambulatory and inpatient teaching, while their

own clinical workload keeps increasing. For teachers to

succeed at their teaching tasks, faculty development is

essential (Wilkerson & Irby 1998). Faculty development also

helps teachers build important professional relationships with

peers and mentors within and outside their institutions and

contribute positively to academic advancement overall

(Morzinski & Fisher 2002).

Summary of professional development programmes.

Common faculty development formats include train the trainer

workshops or seminars, short courses developed by individual

institutions, sabbaticals, part time or full time fellowships,

scholars programmes and educational workshops at confer-

ences (McLeod et al. 1997; Steinert 1993; 2005; Steinert et al.

2006).

Workshops. The prototypical faculty development pro-

gramme is a short, focused series of workshops, most of

which focus on practical teaching skills development and the

educational strategies directly applicable to those teaching

skills. Studies demonstrate that such programmes serve a

variety of purposes including improving attitudes, self-efficacy,

augmenting self-assessed and actual use of specified teaching

concepts; facilitating faculty’s ability to recognize teaching

deficiencies; and increasing knowledge of teaching principles

and teaching ability.

Fellowships. In part-time fellowships, faculty spend limited

time training at another institution and then work on

educational projects at their home institution. Combining the

training with the practical application of knowledge and skills

at home institutions, such fellowships teach the theory and

practice of critical faculty teaching skills. Full-time fellowships

are designed to prepare the fellows to be full-time medical

educators. Although they include teaching skills, they also

emphasize other important educator roles such as educational

research and educational leadership.

Teaching scholars programmes. Innovative formats have

been developed to link workshops into a more comprehensive

programme to target a broader range of outcomes (Gruppen

et al. 2003). As a result, some institutions have designed

teaching- scholars programmes for their faculty. These

programmes are usually a year long and serve as an immersion

experience for clinical educators and most require their

‘fellow’ to complete some educational project. The Teaching

Scholars Programme for Educators in the Health Sciences at

McGill University (Steinert et al. 2003) and the Medical

Education Scholars Programme (MESP) at the University of

Michigan Medical School (Gruppen et al. 2003) were designed

to create leaders in medical education. These programmes

train faculty to provide curriculum design, improved teaching,

educational research, and institutional leadership.

Courses at conferences. Many conferences hosted by pri-

mary care societies as well as conferences organized by

medical education organizations provide a number of courses

which focus on teaching and education. These courses range

from 90 minute courses to all day courses. Examples of such

conferences include the annual conferences of the AAMC,

AMEE, Society of General Internal Medicine, Association of

Teachers of Family Medicine and the Ottawa conferences.

Co-teaching or peer coaching. In this model, paired physi-

cians focus on developing their teaching skills while sharing

the clinical supervision of trainees (Orlander et al. 2000).

Through teaching, debriefing and planning, co-teachers gain

experience in analysing teaching encounters and develop

skills in self-evaluation. Typically, a junior faculty or fellow is

paired with a senior faculty educator who helps the ‘trainee’

teacher reflect on his/her teaching session.

Educational content. The content of staff educational devel-

opment programmes can be classified under the following key

categories.

. Teaching skills: Teaching skills sessions are designed to

help participants identify their own needs with respect to

teaching skills, and then to practice these skills and receive

feedback from colleagues and the faculty (Pololi et al.

2001). Typical topics included in staff educational develop-

ment include: interactive lecturing, small group discussion,

case based teaching, giving effective feedback, promoting a

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positive learning climate, communication of goals, evalua-

tion of learners, ambulatory and inpatient teaching and

physician patient communication, learner- centred learning,

teaching evidence based medicine, stimulating self-directed

learning, bedside teaching, etc.

. Educational leadership: This is a higher level of educational

development of staff. Having acquired the basic teaching

skills, some educators go on to become educational leaders.

Examples of topics on the leadership track include:

mentoring skills, curriculum development and reform,

leadership and management of work teams, running

effective meetings, small group leadership, time manage-

ment, instituting change, cost-effectiveness etc.

. Miscellaneous: Additional skills include learning about

instructional technology, using computers in clinical teach-

ing and diversity for the learning environment.

Steinert (2005) has described in depth the reasons and goals of

staff development for clinical teachers and also summarized

types of professional development resources available.

Mentoring

Several literature reports indicate that mentoring is a useful

tool in the academic progression of professionals with many

successful academicians attributing their growth and success at

least partially to their mentoring relationships. It has also been

said that good mentors help their proteges achieve their

professional goals more expeditiously. The medical world has

well-established research mentoring programmes, but formal

mentoring programmes for clinical teachers are scant to non-

existent. Mentors can provide guidance, support or expertise

to clinicians in a variety of settings and can also help teachers

to understand the organisational culture in which they work

and introduce them to invaluable professional networks

(Walker et al. 2002).

Most successful clinical educators have achieved their

success by a trial-and-error approach, seeking multiple senior

educators’ advice and mentoring on their growth as educators

or just talking to their peers. If educating is to be a skilled and

scholarly task, educators need mentoring. The ultimate

evidence of a clinical teacher being a professional would be

if they themselves start mentoring their junior or peer

colleagues who wish to achieve professional success in

teaching.

Engaging in educational scholarship

For clinical teachers to attain the highest level of profession-

alism in education and advance academically as educational

innovators and leaders, scholarship is essential. Education

becomes scholarship when it demonstrates current knowledge

of the field, invites peer review, and involves exploration of

students’ learning. Furthermore, educational work should be

made public, available for peer review and reproduced and

built on by others (Glassick 2000). Glassick also described six

essential criteria of scholarship.

(1) Clear goals

i. The purpose of the work is clearly stated

ii. The goals and objectives are realistic and

achievable

iii. The work addresses an important question or need

(2) Adequate preparation

i. Mastery and understanding of current knowledge

in the field and acquisition of skills to carry out the

work

ii. Identifying and obtaining the resources needed to

complete the work

(3) Appropriate methods

i. Using and applying appropriate methods to

achieve the stated goals

ii. Modification of methods to deal with changing

circumstances

(4) Significant results

i. Achievement of the stated goals and objectives

ii. The work should add to the field and open up

additional areas for further exploration

(5) Effective presentation

i. Using suitable style and organization to present the

work at appropriate venues

ii. Presentation of results with clarity and integrity

(6) Reflective critique

i. The scholar critically evaluates his or her own work

ii. The scholar uses evaluations to improve the quality

of future work

Points for reflection

(1) How can change be sustained – Change in teaching

skills as well as change in attitudes towards teaching?

Other educators have shown that a one-shot approach to

educational development does not sustain change and staff

development should be longitudinal. Moreover, the educa-

tional environment and institutional attitudes towards teaching

need to change in order that teaching skills are considered as

valuable as research skills in academia.

(2) Can improving clinical teaching skills and excellence in

clinical care co-exist? How can teaching initiatives be

reconciled with the demands of service?

Clinicians face increasing pressures in their clinical practice

and the volume of patients they care for keeps increasing.

Time to see patients keeps shrinking and has often been stated

as one of the foremost barriers to clinical teaching.

Departments and institutions must see high quality teaching

as one of their core values; maybe create a core group of

faculty who would be responsible for much of the teaching.

(3) Does improvement in clinical teaching matter to patient

care? If teaching skills improve, what is the impact on

patient management, safety and satisfaction?

This is an area that has not been investigated extensively and is

a difficult area to research. Regardless, unless medical educators

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demonstrate that improved teaching leads to improved patient

outcomes, the public and other stake holders may not see the

value of allocating dedicated time to teaching.

(4) How should teachers be evaluated – What outcomes

should be measured and who should evaluate them?

Most clinical teachers are evaluated by their trainees, often

irregularly and inconsistently. Frequently trainee evaluations

are subjective and cursory, thereby of little help to teachers

who wish to improve their teaching skills. Trained peers,

acting as coaches, may be one of the more useful ways to

evaluate teaching, but time needs to be set aside for this

coaching model. Microteaching or videotaping of teaching

encounters can be invaluable in allowing self-assessment of

teaching, but can this be carried out in the clinical

environment?

(5) How can institutions and departments elevate the value

of clinical teaching – The hidden curriculum, reward its

teachers and nurture educational leaders?

In the clinical world, research accomplishments are often held

in higher esteem than educational achievements. Expanding

academic tracks, staff development, rewarding teachers and

establishing clear criteria by which educators can be promoted

are possible ways to elevate the value of teaching within

institutions and departments.

(6) Teaching clinical skills, bedside teaching – do they

really matter? Can technology answer all diagnostic

questions?

For better or for worse, technology is here to stay in medicine.

Clinical teachers can model appropriate use of technology

in making the best clinical decisions and teach trainees

the respective value of clinical data and laboratory data in

patient care. Educators can further use technology to

demonstrate the precision of clinical signs, discarding those

that of little value.

(7) How can a clinical teacher set educational

objectives when much of the learning is opportunistic?

How can teachers respond to the unexpected teaching

moments?

Teaching in the clinical environment is beset by frequent

unexpected teaching challenges. Questions arise from patients

or trainees that teachers are unprepared to answer; patient

mood or severity of illness can displace preset teaching

objectives. Setting a positive educational environment where

teachers are willing to admit their limitations, show willingness

to learn from trainees and are prepared to set aside their

teaching objectives while grabbing the unexpected moment

and doing opportunistic teaching are some strategies to

overcome these challenges.

(8) How should teachers inform and orient patients about

the teaching nature of the session – Are patients

benefiting from the teaching?

If physicians are to learn from direct patient care, patients

should be fully engaged in the teaching encounter. Several

reports state that most patients enjoy participating in clinical

teaching. A few common sense strategies can maximise their

impact; introductions, orientation of patients, professionalism,

patient education etc, to name a few.

(9) How can a clinical teacher target their teaching

to multiple levels of learners and keep them all

engaged?

A typical clinical team often consists of multiple levels of

trainees from early students to senior house officers and

beyond. Clinicians are often intimidated by having to engage

all levels during their teaching encounters. Some ways to

achieve this successfully include: giving assignments for

Box 8. Practical strategies to achieve Circle-3 clinical teaching outcomes: The teacher as a professional(the right person doing it)

Teaching objectives

Do you establish teaching goals for different types of clinical encounters?

Did you communicate your teaching goals to the learners?

Did you elicit goals of the learners?

Teaching methods

What teaching methods did you use and were they successful (demonstrating, observing, questioning, role-modelling)?

Do you use the same teaching strategies for all learners or do you change your methods for different learner levels and skills?

Feedback

Did you give feedback?

Did you ask for learners’ feedback on your teaching?

Planning for the next encounter

Have you used reflective critique of your teaching (from self-assessment or peer or learner feedback) to change your teaching methods?

Professional development

Have you attended courses, studied educational literature or held discussions with other teachers to improve your teaching skills?

Are you planning to engage in the scholarship of teaching, study the impact of your interventions?

AMEE Guide no. 34: Teaching in the clinical environment

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trainees to prepare ahead of time, allocating specific tasks at

the bedside and using senior trainees to participate in the

teaching.

Quotes for Teaching in the ClinicalEnvironment

Summary: Teaching in the clinical environment is a demand-

ing, complex and often frustrating task, a task many

clinicians assume without adequate preparation or

orientation.

Introduction: Due to advances in education such as new

methods of teaching and learning, a more student-centred

teaching, competency based assessment and emphasis on

professionalism; educators today are required to have an

expanded toolkit of teaching skills and clinical expertise

General Teaching models: Two models of clinical teaching

have been successfully used in faculty development of

clinical teachers. Both models are behaviour based and

can be adapted by clinical teachers to all clinical settings.

Stanford Model: Although it (the Stanford model) provides a

categorical framework for evaluation and analysis of

teaching, the power of the model is most effectively

demonstrated in hands-on seminars in which faculty are

enabled to both understand and apply this method of

analysis to their teaching.

One minute preceptor: The ‘Microskills’ of teaching, also called

the one minute preceptor because of the short time

available for teaching in the clinical environment provides

a simple framework for daily teaching during patient care.

Applying the Dundee model: It has been stated that the

medical profession needs to think more seriously about

training their teachers and a framework for developing

excellence as a clinical educator is needed.

Time efficient teaching: Irby & Bowen (2004) described a

3-step approach for time efficient teaching in the clinical

environment. All three steps described can be adapted

equally well to a one-hour session as a 10-minute teaching

session.

Inpatient teaching: Ende (1997) wrote that the role of the

inpatient teacher is one of the most challenging in medical

education, that of a master, mentor, supervisor, facilitator,

or all of the above.

Outpatient teaching: In recent years, the outpatient clinics

have become an integral venue to teach clinical medicine.

With shorter hospital stays, it has become impossible for

trainees to follow and learn the natural history of a disease

from the inpatient environment.

Teaching at the bedside: It has been stated that since clinical

practice involves the diagnosis and management of

problems in patients, teaching of clinical medicine should

be carried out on real patients with real problems (Nair

et al. 1997).

Work based assessment: Assessment plays a major role in the

process of medical education, in the lives of medical

students, and in society by certifying competent physi-

cians who can take care of the public. Society has the right

to know that physicians who graduate from medical

school and subsequent residency-training programmes are

competent and can practise their profession in a

compassionate and skilful manner.

Giving feedback: It (feedback) is a crucial step in the

acquisition of clinical skills, but clinical teachers either

omit to give feedback altogether or the quality of their

feedback does not enlighten the trainees of their strengths

and weaknesses.

How the teacher approaches their teaching: The starting point

for any good teacher must be enthusiasm for the subject

being taught. This has to be complemented by an

eagerness to transmit this enthusiasm to others, which

will necessarily result in a positive attitude to learners.

Learning and memory: There is an extensive literature on

learning and memory. There appears to be a consensus

that different models apply for the learning of knowledge

and the acquisition of skills. Clinical teaching must deliver

both modalities.

Learning styles: It is apparent that different individuals have

different approaches to learning. There have been a

variety of attempts to describe these different approaches

or learning style. Some classifications focus on the

cognitive aspects of learning; some focus on the mod-

alities of learning preferred by the learners; a third group

focus on the outcomes of the learning.

Knowing and applying feedback: These principles of feedback

include the use of mutually agreed upon goals as a guide

to the feedback; addressing specific behaviours not

general performance; reporting on decisions and actions

not on one’s interpretation of the student’s motives; and

using language that is non-evaluative and non-

judgemental.

Role modelling: An important part of clinical reaching is the

development of the professional role in the students. Both

trainees and faculty) agree that the observation of role

models is the most important component in this process.

Soliciting feedback on teaching: Teachers should be encour-

aged to seek feedback on their teaching from peers and

learners, staff development should train teachers in

efficiently obtaining feedback and last but not least a

teaching consulting or coaching service developed by

institutions for clinical teachers would help improve

teaching skills of individual teachers as well as the

institution as a whole

Workshops: The prototypical faculty development programme

is a short, focused series of workshops, most of which

focus on practical teaching skills development and the

educational strategies directly applicable to those teaching

skills.

Notes on contributors

DR. SUBHA RAMANI, MD, MMEd, MPH is a general internist and medical

educator. She completed Internal Medicine residencies in India and the

United States. She has undergone extensive training in medical education

including the Stanford Faculty Development Programme, the Dundee

Discovery Courses in Medical Education and the Harvard Macy Programme

for Physician Educators and completed a Masters in Medical Education

from the University of Dundee in 2005. Her major areas of interest are

clinical teaching methods, bedside teaching and teaching and assessment

of clinical skills. She is the Director of Clinical Skills development for the

S. Ramani & S. Leinster

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Internal Medicine Residency Programme and Associate Professor of

Medicine at the Boston University School of Medicine.

PROFESSOR SAM LEINSTER FRCS (Ed), FRCS (Eng) MD is presently the

Dean of the School of Medicine, Health Policy and Practice, East Anglia

Medical School, and Non-Executive Director and General Surgeon of

Norfolk and Norwich Hospital Trust. He was previously Director of Medical

Studies and Professor of Surgery at the University of Liverpool where he

designed and implemented an acclaimed new curriculum for under-

graduate medicine and he has also established the Breast Unit at the Royal

Liverpool University Hospital. He is involved internationally in many

aspects of medical education and an active member of the Association for

the Study of Medical Education (ASME).

References

Branch WT Jr, Paranjape A. 2002. Feedback and reflection: teaching

methods for clinical settings. Acad Med 77:1185–1188.

Brandsford J, Brown AL, Cocking RR, editors. 1999. How People Learn:

Brain, Mind, Experience and School (Washington, National Academy

Press).

Brownell AK, Cote L. 2001. Senior residents views on the meaning of

professionalism and how they learn about it. Acad Med 76:734–737.

Chapman A. 2007. Conscious competence learning model. Available online

at: http://www.businessballs.com/consciouscompetencelearningmo-

del.htm (accessed 8 October 2007).

Ende J. 1983. Feedback in clinical medical education. Journal of the

American Med Assoc 250:777–781.

Ende J. 1997. What if Osler were one of us? Inpatient teaching today. J Gen

Intern Med 12(Suppl 2):S41–48.

Fryer-Edwards K, Arnold RM, Baile W, Tulsky JA, Petracca F, Back A. 2006.

Reflective teaching practices: an approach to teaching communication

skills in a small-group setting. Acad Med 81:638–644.

Glassick CE. 2000. Boyer’s Expanded Definitions of Scholarship, the

Standards for Assessing Scholarship, and the Elusiveness of the

Scholarship of Teaching. Acad Med 75:877–880.

Gruppen LD, Frohna AZ, Anderson RM, Lowe KD. 2003. Faculty

development for educational leadership and scholarship. Acad Med

78:137–141.

Harden RM, Crosby JR. 2000. AMEE Guide No 20: The good teacher is more

than a lecturer: the twelve roles of the teacher. Med Teach 22:334–347.

Harden RM, Crosby JR, David MH, Friedman M. 1999. AMEE Guide No. 14:

Outcome-based education: Part 5-From competency to meta-compe-

tency: a model for the specification of learning outcomes. Med Teach

21:546–552.

Hesketh EA, Bagnall G, Buckley EG, Friedman M, Goodall E, Harden RM,

Laidlaw JM, Leighton-Beck L, Mckinlay P, Newton R, Oughton R. 2001.

A framework for developing excellence as a clinical educator.

Med Educ 35:555–564.

Hewson GM, Little ML. 1998. Giving feedback in medical education:

verification of recommended techniques. J Gen Intern Med 13:111–116.

Honey P, Mumford A. 1992. The Manual of Learning Styles (Maidenhead,

Peter Honey Publications).

Irby DM, Bowen JL. 2004. Time-efficient strategies for learning and

performance. Clin Teach 1:23–28.

Irby DM, Papadakis M. 2001. Does good clinical teaching really make a

difference? Am J Med 110:231–232.

Kaufman DM. 2003. Applying educational theory in practice. Br Med J

326:213–216.

Kenny NP, Mann KV. 2003. Role modelling in physicians’ professional

formation: reconsidering an essential but untapped educational

strategy. Acad Med 78:1203–1210.

Knowles MS. 1990. The Adult Learner: A neglected species, 4th edn

(Houston, Texas, Gulf Publishing).

Kolb DA. 1984. Experiential Learning: Experience as a Source of Learning

and Development (Chicago, Prentice Hall, Eaglewood Williams Cliffs).

Kroenke K. 2001. Attending rounds revisited. (President’s column). Soc

Gen Intern Med Forum 24:8–9.

LaCombe MA. 1997. On bedside teaching. Ann Intern Med 126:217–220.

Lave J, Wenger E. 1991. Situated Learning: Legitimate Peripheral

Participation (UK, Cambridge University Press).

Litzelman DK, Stratos GA, Marriott DJ, Skeff KM. 1998. Factorial validation

of a widely disseminated educational framework for evaluating clinical

teachers. Acad Med 73:688–695.

McGee SR, Irby DM. 1997. Teaching in the outpatient clinic. Practical tips.

Journal of General Internal Medicine 12(Suppl 2):S34–40.

Mcleod PJ, Steinert Y, Nasmith L, Conochie L. 1997. Faculty development in

Canadian medical schools: a 10-year update. Canadian Medical

Association Journal 156:1419–1423.

Miller G. 1990. The assessment of clinical skills/competence/performance.

Acad Med 65:s63–s67.

Morzinski JA, Fisher JC. 2002. A nationwide study of the influence of faculty

development programs on colleague relationships. Acad Med

77:402–406.

Nair BR, Coughlan JL, Hensley MJ. 1997. Student and patient perspectives

on bedside teaching. Med Educ 31:341–346.

Neher J, gordon KC, Meyer B, Stevens N. 1992. A five-step

‘microskills’ model of clinical teaching. J Am Board Family

Practitoners 5:419–424.

Newble DI, Entwhistle NJ. 1986. Learning styles and

approaches: implications for medical education. Med Educ

20:162–175.

Norcini JJ. 2003. Work based assessment. Br Med J 326:753–755.

Orlander JD, Gupta M, Fincke BG, Manning ME, Hershman W. 2000.

Co-teaching: a faculty development strategy. Med Educ 34:257–265.

Pololi L, Clay MC, Lipkin M JR, Hewson M, Kaplan C, Frankel RM. 2001.

Reflections on integrating theories of adult education into a medical

school faculty development course. Med Teach 23:276–283.

Prideaux D, Alexander H, Bower A, Dacre J, Haist S, Jolly B, Norcine J,

Roberts T, Rothman A, Rowe R, Tallett S. 2000. Clinical teaching:

maintaining an educational role for doctors in the new health care

environment. Med Educ 34:820–826.

Ram P, Grol R, Rethans JJ, Schouten B, Van der Vleuten C, Kester A. 1999.

Assessment of general practitioners by video observation of commu-

nicative and medical performance in daily practice: issues of validity,

reliability and feasibility. Med Educ 33:447–454.

Ramani S. 2003. Twelve tips to improve bedside teaching. Med Teach

25:112–115.

Ramani S, Orlander JD, Strunin L, Barber TW. 2003. Whither bedside

teaching? A focus-group study of clinical teachers. Acad Med

78:384–390.

Rethans JJ, Norcini J, Baron-Maldonado M, Blackmore D, Jolly BC,

Laduca T, Lew S, Page GG, Southgate LH. 2002. The relationship

between competence and performance: implications for assessing

practice performance. Med Educ 36:901–909.

Schmidt HG. 1983. Problem-based learning: rationale and description. Med

Educ 17:11–16.

Schon DA. 1987. Educating the Reflective Practitioner: Toward a New

Design for Teaching and Learning in the Professions (San Francisco,

Jossey-Bass).

Schon DA. 1995. The Reflective Practitioner: How Professionals Think in

Action (New York, Basic Books).

Searle NS, Hatem CJ, Perkowski L, Wilkerson L. 2006. Why Invest in an

Educational Fellowship Program? Academic Medicine 81:936–940.

Sender Liberman A, Liberman M, Steinert Y, McLeod P, Meterissian S. 2005.

Surgery residents and attending surgeons have different perceptions of

feedback. Med Teach 27:470–472.

Shapiro I. 2001. Doctor means teacher. Acad Med 76:711.

Shumway JM, Harden RM. 2003. AMEE Guide No. 25: The assessment of

learning outcomes for the competent and reflective physician. Med

Teach 25:569–584.

Skeff KM. 1988. Enhancing teaching effectiveness and vitality in the

ambulatory setting. J Gen Intern Med 3:S26–S33.

Spencer J. 2003. Learning and teaching in the clinical environment. Br Med

J 326:591–594.

Steinert Y. 1993. Faculty development in family medicine. A reassessment.

Can Fam Phys 39:1917–1922.

Steinert Y. 2005. Staff development for clinical teachers. Clin Teach

2:104–110.

Steinert Y, Mann S, Centeno A, Dolmans D, Spencer J, Gelula M,

Prideaux D. 2006. BEME guide. A systematic review of faculty

AMEE Guide no. 34: Teaching in the clinical environment

363

Med

Tea

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development initiatives designed to improve teaching effectiveness

in medical education. BEME Guide No. 8. 28:497–526.

Steinert Y, Nasmith L, McLeod PJ, Conochie L. 2003. A teaching scholars

program to develop leaders in medical education. Acad Med

78:142–149.

Vygotsky LS. 1978. Mind and Society: The Development of Higher Mental

Processes (Cambridge, MA, Harvard University Press).

Walker WO, Kelly PC, Hume RF. 2002. Mentoring for the New Millennium.

Med Educ. Available online at www.med-ed-online.org (accessed

15 August 2007).

Wilkerson L, Irby DM. 1998. Strategies for improving teaching practices: a

comprehensive approach to faculty development. Acad Med

73:387–396.

Williams GC, Saizow RB, Ryan RM. 1999. The importance of

self determination theory for medical education. Acad Med

74:992–995.

Wolpaw TM, Wolpaw DR, Papp KK. 2003. SNAPPS: a learner-centred

model for outpatient education. Acad Med 78:893–898.

Wright SM, Carrese JA. 2002. Excellence in role modelling: insight and

perspectives from the pros. Can J Med 167:638–643.

S. Ramani & S. Leinster

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Balance: Can you have Balance: Can you have it all?it all?

Susan M. Gilmour, Susan M. Gilmour, MScMSc, MD, FRCPC, MD, FRCPCChair, Department of PediatricsChair, Department of Pediatrics

University of AlbertaUniversity of AlbertaStolleryStollery ChildrenChildren’’s Hospitals Hospital

Have it all?Have it all?

YesYes…….but you just can.but you just can’’t have it t have it all at onceall at once……

Balancing What?Balancing What?

CareerCareer PatientsPatients

CoCo--workersworkers

PeersPeers

SupervisorsSupervisors

Relationships/familyRelationships/family

SelfSelf

WorkWork--Life Balance: Fact or Life Balance: Fact or Fiction?Fiction?

Imbalance = StressImbalance = Stress

Stress effects both physical and Stress effects both physical and mental health and we become mental health and we become more dissatisfied with our lifemore dissatisfied with our life

Stress results in $10 billion due Stress results in $10 billion due to absenteeism and $14 billion to absenteeism and $14 billion in healthin health--care (Canadian data)care (Canadian data)

““Leave work too early and get Leave work too early and get home too latehome too late””

If you canIf you can’’t stand the heat dont stand the heat don’’t t become a become a soussous chef (chef (……or a or a doctordoctor……) ) GlobeGlobe and Mail,and Mail, December 2010)December 2010)

HealthHealth--care care practionerspractioners have have poorer balancepoorer balance Self neglect/denialSelf neglect/denial

Lack of boundaries between work Lack of boundaries between work and homeand home

Mental healthMental health

Substance abuseSubstance abuse

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MultiMulti--taskingtasking

DoesnDoesn’’t existt exist Rapid Rapid

succession of succession of single focus single focus taskstasks

Choose your Choose your taskstasks

Say noSay no Be engaged in Be engaged in

the presentthe present

Combating StressCombating Stress

No single formula: Cultivate No single formula: Cultivate habits of personal renewalhabits of personal renewal Emotional selfEmotional self--awarenessawareness

Healthy habitsHealthy habits

Connection with colleaguesConnection with colleagues

Adequate support systemsAdequate support systems

Ability to find meaning in workAbility to find meaning in work

Job SatisfactionJob Satisfaction

DoesnDoesn’’t come from outsourcing t come from outsourcing the rest of your lifethe rest of your life

DoesnDoesn’’t come from financial t come from financial incentivesincentives

Comes from meaningful input Comes from meaningful input (not the same thing as control)(not the same thing as control)

Solving problemsSolving problems……

““DonDon’’t worryt worry……be happybe happy””

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Depression and Burnout in Medical Training

Burnout is a syndrome of emotional exhaustion, depersonalization, and low personal accomplishment. Often, it can lead to decreased effectiveness at work. Burnout is different from depression in that it usually only involves a person’s relationship to work, whereas depression is more global.1

As documented in multiple studies, burnout and depression occur at high rates among house officers across many specialties. In a recent survey study of 123 residents at three pediatric residency programs, 20% of participating residents met criteria for depression, and 74% met criteria for burnout.2

Burnout Emotional exhaustion: - Emotionally drained from work - Depleted at the end of the workday - Tired when you have to face another day of work - You are working too hard on your job - Frustrated with work - As though you are at the end of your rope Depersonalization: - As though you do not have compassion for patients and/or colleagues - More callous toward people as a result of your job - Work seems to be hardening you emotionally - Indifferent about what happens to people at work - Blamed by people at work Low sense of personal accomplishment: - Loss of empathy for others at work - Loss of effectiveness in dealing with the problems of others at work - Loss of energy - Exhausted when you work closely with others - Unsure whether you really accomplish anything worthwhile at work - Loss of ability to remain calm when dealing with emotional problems at work

Depression Major Depression Diagnosis of major depression requires at least five of nine symptoms (must include one of first two) for at least two weeks: - Depressed mood - Markedly diminished pleasure or interest in activities - Significant weight loss or weight gain - Insomnia or excessive sleep - Agitated movements or very slow movement - Fatigue or loss of energy

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- Feelings of worthlessness or guilt - Impaired concentration and indecisiveness - Thoughts of death or suicide Atypical depression People with atypical depression have some, but not all, of the same features of major depression. They often have prominent physical symptoms, including weight changes and sleep disturbances, especially excessive sleep.

Dysthymia Dysthymia is a chronic, low-grade depression that persists for a long period of time, usually two consecutive years, with no more than two months at a time free of symptoms. The prominent symptoms include an absence of pleasure or interest in activities, low self-esteem, low energy, and poor sleep and concentration.

Accompanying Materials: Bernstein, Mark. Neurosurgical depression. Canadian Medical Association Journal. 2003: 169(9); 943-944. Malach-Pines Short Burnout Measure. Courtesy of the Office of Clinician Support, Children’s Hospital Boston. References: 1. Shanafelt TD et al. Burnout and self-reported care in an internal medicine residency program. Annals of Internal Medicine 2002: 136(5); 358-367. 2. Fahrenkopf, Amy et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ 2008;336:488-91. 3. Sotile, W and Sotile, M. The Resilient Physician. American Medical Association, 2002. 4. Up-To-Date Online, 15.3. Patient Information: Depression in Adults.

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Office of Clinician Support, Children’s Hospital Boston: A Safe Place to Talk

For Appointments, please call (617) 355-6705

Burnout is a common problem among healthcare givers. You can use the following measure to assess your level of burnout.

Please use the following scale to answer the question: When you think about your work overall, how often do you feel the following?

Nev

er

Alm

ost N

ever

Rar

ely

Som

etim

es

Oft

en

Ver

y O

ften

Alw

ays

1 2 3 4 5 6 7 Tired Disappointed with people Hopeless Trapped Helpless Depressed Physically Weak/Sickly Worthless/Like a Failure Difficulties Sleeping "I've had it"

To calculate your burnout score add up your responses and divide by 10: ________ A score of up to 2.4 indicates low level of burnout; 2.5-3.4 indicates danger of burnout; 3.5-4.4 indicates burnout; 4.5-5.4 indicates serious burnout; a score of 5.5 or higher is suggestive of a need for immediate professional help. Hospitals are complex environments. Taking care of sick patients, especially children, can be very demanding and emotionally draining. Academic pressure, hospital regulations, and differences among staff can also contribute to workplace stress. The Office of Clinician Support is a safe place to talk. Even a few minutes can help reduce your distress. The Office of Clinician Support can be a first step. For appointments, please call 617-355-6705.

Burnout Measure: Short Version (Malach-Pines, 2005)

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tient — and alcoholic — who has lefthospital before completing his treat-ment. They deliver the meds, making atiny inroad into a significant publichealth problem.

Meanwhile, in the Congo, a nurseand logistician from the Netherlandsembark on a 550-km reconnaissancemission to assess the need for a mobileclinic in the “land of the living skele-tons,” a forgotten region near Lolon-golokonga. Peter Rietveld is also tryingto understand the cachexia that afflictsmany inhabitants of the area. Question-ing and observation lead him to suspectan association with endemic river blind-ness — and with abject poverty.

Episode 4, “Borders and Babies” (air-ing Oct. 30 and Nov. 2), features work inSierra Leone and on the border betweenPakistan and Afghanistan. Canadian

nurse Katiana Rivette, in her early daysas head of the maternity ward at Magbu-raka hospital, tries to save a baby whosemother is dying of pre-eclampsia: bothsuccumb. (Was it necessary to show thiswoman’s breasts? Was patient permis-sion obtained? We don’t know.) Thisepisode also features the heart-wrench-ing story of the boy with osteosarcoma.

In Freetown, we catch American Re-becca Golden wrapping up seven yearsas head of the MSF mission in SierraLeone. She admits to being tired — “Iwant to get out from underneath theresponsibility” — but at the same timeshe loves the country and returns to theUS with trepidation.

In Chaman, Afghanistan, BritonVickie Hawkins supervises logistics andmedical care for the thousands ofrefugees streaming across the border.

She also cuts through red tape to get aseriously ill man admitted to hospital.Her frustration simmers, but she can’tshow it. “It’s unstable, volatile, even vi-olent. So, what am I doing here?” sheasks. “I love it!”

This enthusiasm is the thread thatjoins all the MSF staff and volunteersencountered. “A life-changing experi-ence,” says Friend. “I want to change theworld,” says Rivette at the start of herterm. Within a week she’s changed hertune: “I can’t save the world, or SierraLeone, or a village. I’m just here to sharea little bit of my knowledge. For sureI’m going to gain more than I give.”

Lampard aptly sums it up: “At theend of the day, I sleep a little better.”

Barbara SibbaldCMAJ

The Left Atrium

CMAJ • OCT. 28, 2003; 169 (9) 943

Room for a view

Neurosurgical depression

He wakes up soaked in sweat at 3:30am, rescued by consciousness

from a string of nightmares. The firstwas about a new reality show on televi-sion in which all of the male contestantsagreed to have their penises cut off ifthey didn’t win. The victims seemed totolerate the insult with equanimity.

He rolls out of bed, panting withpanic. There is no point in trying tosleep a little longer. It doesn’t take abrain surgeon to understand that thisman has feelings of inadequacy and in-security and is tormented by demons.

He gets dressed, fumbling with hisshirt buttons and the knot in his tie. It’san awkward process: the end of hisdominant thumb is split from the drywinter air and he doesn’t want to re-open it and bloody his clothes. He triesto get downstairs quietly, to avoid wak-ing his wife and daughters, but hischocolate Labrador emerges fromnowhere and trips him up in the dark.Body and briefcase go sprawling. Hisolder dog, a big yellow lab, pads downthe hall to check things out; she licks his

head, sticking her tongue up his nose. This is his laugh for the day. He

pulls himself up, resigned to the blonddog hair now clinging to his meticu-lously kept clothes. He stumbles down-stairs and throws on his coat. The air isfrigid; he feels hisway in the dark tothe car. The enginewon’t be warm untilhe pulls into theparking lot at thehospital. For threehours he answersemails, dictates dis-charge summaries,listens to jazz on theradio, and works on revisions of a man-uscript that he is so proud of and thatthree journals have rejected so far.

He goes downstairs to the coffee barand gets a large regular coffee, his onlymeal of the day. The hospital still has anearly, empty feeling: there’s no one elsein line. At 7:45 a.m. he goes to the oper-ating room. His first patient needs to bedelayed; she has had a sore throat since

yesterday and has started to wheeze. Herelective back surgery was booked amonth ago. He chats with the anesthesi-ologist, who suggests they start with oneof his two other cases — both young,both requiring removal of a brain tu-

mour. The OR nurses,his second family, curseunder their breath be-cause they already hadthe room set up for thelumbar discectomy andhave to rearrange it.

He gets through thetwo tumour surgeriesand the sweet little ladywith the back problem is

deemed fit for surgery after inhalingfrom some puffers. So he gets all threecases done. Much of the surgical day isspent fussing over residents and fellowsto do the surgery as well as he wouldbut in twice the time it would take him.And one of the really good OR nursesis in a manic phase and is exhausting tobe with; he’s usually the only manic onein the OR.

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Page 86: NASPGHAN/NESTLÉ NUTRITION INSTITUTE · Greg Kobak/Elaine Moustafellos/Alan ... dr_ghassan@hotmail.com Hamilton Canada Beasley Genie genie@peds ... York NY DeBosch Brian debosch_b@kids.wustl.edu

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944 JAMC • 28 OCT. 2003; 169 (9)

At the end of the day he makes quickrounds with the residents to make sureall is well: another day of doctors tri-umphing over disease. He ought to feelexhilarated. All of the surgeries havegone well, but he knows that the secondpatient will not graduate from college intwo years; her cancerous brain tumourwill have claimed her by then.

He stumbles back to his office at6:00 p.m. to do paperwork and getshome at 8:30. His dogs greet him en-thusiastically; his wife and daughtersless so. His wife smiles wryly and tossesa meaningful glance toward the girls.Another family supper missed. He sum-mons a loud “Hi” for each of his daugh-ters; they reply with garbled grunts. Hemakes a gin and tonic and after gulpingit in 20 seconds pours a glass of redwine to lubricate the rapid downing ofhis first meal in 24 hours. He has a bathand pours a scotch and takes it with atall glass of water to his study, where heturns on the computer to check emails.He writes a tormented piece like thisone and falls asleep watching television,trying to dream about fishing or being amonster jazz saxophonist. He loves hisfamily and they love him, but every-one’s struggling with the same thing heis. At 3:30 a.m. he wakes up and does itagain.

He’s a little depressed, pal. But hashe figured it out yet?

The next evening he gets a phonecall from one of his daughters, who isout on the town with friends. Shesounds so grown-up, yet so dear andtender — the youngest of three pre-cious daughters, who was born with alarge birth-mark on her upper lip thateventually faded, who had a few febrileseizures as a baby that scared him andhis wife shitless, and who is strugglingwith the things teenagers struggle with.Before he hangs up he tells her howmuch he loves her. Then he sits on theside of the bed and sobs like a baby.

He’s a really depressed man. Whatis he going to do about it?

Mark BernsteinNeurosurgeonToronto Western HospitalToronto, Ont.

Lifeworks

A terrible beauty

“While we may be flesh-colouredon top,” says artist Patricia

Chauncey, “there’s a whole lot morethat’s underneath us that is actuallyshockingly beautiful.”

Chauncey’s textile art pieces vividlyillustrate this idea. Some look likechunks of dinosaur hide, others likemagnifications of animal cells or tissuesamples. One looks like somethingyou’d glimpse in an antismoking ad: athick, textured mat of moist greys,browns and purples. All are potent andorganic, like things excavated from theearth or the human body and exposedto daylight for the first time.

Chauncey has been interested in or-ganic and biological subjects for a longtime, having spent many childhoodhours looking for dinosaur bones in theAlberta badlands. She has used medicalimagery in her work for years, while do-ing art shows, designing and distressingcostumes for the film industry, and rais-ing a family in Vancouver.

Although she had been feeling sickfor years, she was diagnosed with an ag-gressive form of breast cancer only lastyear. “By the time they found the tu-mour in my body it was the size of agrapefruit ... . I had a lymph node thatwas completely replaced by cancer. So, Imoved instantly from not knowing Ihad cancer into metastatic cancer.”Fighting her cancer, she’s come to in-corporate her awareness of her bodyinto her art.

“Since I’ve been diagnosed with can-cer ... I’ve had the opportunity, verydifferently than most people who arehealthy, to see what that looks like. I’veseen what my cells look like, I knowwhat my DNA is like, I know what myskeleton looks like. I've been living upin the library in the cancer clinic. Peo-ple think I’m reading to find out if Ican improve my situation ... . Butwhat’s amazing to me is the visuals ofit. I’m absolutely fascinated by thebeauty of cells, and by how magical theconnection between body parts andeverything is. ... [Cells] are like gar-dens, they’re like little constellations. Imean they’re just absolutely amazing.Sometimes the cells that are pretty arethe ones that are sick.”

These are the images and ideas thatChauncey incorporates into her art. Sheworks in destructive textiles, which in-volves “slashing, cutting, burning, melt-ing and leaving [metal] in the yard torust, and applying different kinds of ma-terials so that the textile takes on a dif-ferent form. You can start with a plaincotton and come out with somethingentirely different, or a plain white pieceof polyester and have something that’svery three dimensional and very carved-up, very mineral-like. It takes on com-pletely different qualities.” Her workalso includes embroidery, dyeing, print-ing and silkscreen techniques. She stud-ied at Capilano College under LeslieRichmond, one of the world’s foremostdestructive textile artists.

Some of her work consists of mem-Patricia Chauncey, 2001. Flesh (detail)

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