Using personality style preferences to enhance teaching in obstetrics and gynecology.

Using personality style preferences as the basis for faculty development workshops, physician educators in several departments of obstetrics and gynecology learned how to use these differences to enhance clinical teaching. Data from five workshops are analyzed to determine the predominant personality styles of 184 department chairmen, faculty, and residents in obstetrics and gynecology. Chairmen had a stronger preference for taking charge than faculty or residents. As a whole, all preferred use of logic and action in pursuit of excellence. These findings are discussed in relation to student ratings of faculty clinical teaching and to faculty development.

Longitudinal analysis of a multisite clerkship.

Monitoring the quality of well-established multisite clerkships can be aided by the use of trend analysis and graphic-oriented presentations. Five years of data on student performance, experience, and perceptions are reported for an obstetrics and gynecology clerkship offered at eight geographically dispersed sites. Of the five measures of student performance, two (final written and oral examinations) showed major changes. Trends also appeared in student participation in deliveries and student ratings of teaching over time. The results of these analyses were communicated to faculty at each site and used to make improvements in the clerkship. The implications and use of these longitudinal evaluation procedures are discussed.

How attending physicians make instructional decisions when conducting teaching rounds.

When attending physicians are conducting teaching rounds, they rapidly decide what and how much to teach in response to each case presentation. How do they make these instructional decisions? The author performed a qualitative study of the instructional reasoning and actions of six distinguished clinical teachers in general internal medicine to address this question. Four data sources were used: interviews with teachers and learners, a structured task, transcripts of teaching rounds, and week-long observations of each ward team. The teachers in this study engaged in substantial amounts of planning before rounds and reflected on rounds afterwards. When listening to a case presentation during rounds, they quickly diagnosed the patient's problems and simultaneously diagnosed their learners' levels of understanding. These diagnostic assessments were used to tailor content-specific curriculum scripts for instruction. Throughout the rounds, the teachers also engaged in interactive thinking, decision making, and improvisation. The author's findings allowed him to hypothesize a model of clinical instructional reasoning and action; they contribute new insights into the interplay between reasoning in a discipline and pedagogical reasoning. Instructional reasoning and clinical reasoning were found to be closely linked through the use of scripts. The implications of these and other findings for medical faculty development are discussed.

Three exemplary models of case-based teaching.

Teaching in response to case presentations is an essential feature of clinical teaching in medicine. Yet, this form of case-based teaching is often done poorly. Using qualitative methods of interviews, observations, and recordings of teaching rounds, the author describes three different yet exemplary pedagogical strategies for organizing teaching rounds in general internal medicine. These include: (1) case-bedside teaching that involves case discussion in a conference room followed by demonstrations at the bedside, (2) case-lecture teaching that blends quick reviews of cases with more formal presentations on relevant topics, and (3) case-iterative teaching that involves discovery-learning using complex cases. From these three case studies, five general principles of experiential learning in clinical settings are derived: anchoring instruction in cases, actively involving learners, modeling professional thinking and action, providing direction and feedback, and creating a collaborative learning environment. These three approaches to teaching rounds overcome common problems associated with learning in clinical settings.

What clinical teachers in medicine need to know.

In order to identify the components of knowledge that effective clinical teachers of medicine need, the author carried out a qualitative study of six distinguished clinical teachers in general internal medicine in 1991. Using data from interviews, a structured task, and observations of each ward team, he identified six domains of knowledge essential to teaching excellence in the context of teaching rounds: clinical knowledge of medicine, patients, and the context of practice, as well as educational knowledge of learners, general principles of teaching and case-based teaching scripts. When combined, these domains of knowledge allow attending physicians to engage in clinical instructional reasoning and to target their teaching to the specific needs of their learners. The results of this investigation are discussed in relation to both prior research on teacher knowledge, reasoning, and action and faculty development in medicine.

Teaching and learning in ambulatory care settings: a thematic review of the literature.

A thematic review was conducted of the 1980-1994 research literature on teaching and learning in ambulatory care settings for both undergraduate and graduate medical education. Included in the review were 101 data-based research articles, along with other articles containing helpful recommendations for improving ambulatory education. The studies suggest that education in ambulatory care clinics is characterized by variability, unpredictability, immediacy, and lack of continuity. Learners often see a narrow range of patient problems in a single clinic and experience limited continuity of care. Few cases are discussed with attending physicians and even fewer are examined by them. Case discussions are short in duration, involve little teaching, and provide virtually no feedback. Excellent teachers are described as physician role models, effective supervisors, dynamic teachers, and supportive persons. Rather than block rotations, students and residents prefer longitudinal teaching programs, which offer continuity-of-care experiences with patients and preceptors. Although little can be concluded about learning outcomes, the studies indicate that some medical students and residents have deficient skills in interviewing, physical examination, and management of psychosocial issues. Based on the reviewed studies, the author recommends facilitating learning by increasing continuity-of-patient-care experiences and contact with faculty members, encouraging collaborative and self-directed learning, providing faculty development, and strengthening assessment and feedback procedures. The author also recommends further research to learn about medical specialties other than internal medicine and family medicine, to describe the knowledge and reasoning of both teachers and learners, and to assess the influences of various educational programs on learning and satisfaction.

The legal context for evaluating and dismissing medical students and residents.

Medical school faculty often cite the fear of litigation as a reason for their reluctance to offer candid evaluations of students' and residents' performances and to dismiss them when necessary. This article is written to reassure faculty that they have nothing to fear from the courts and that they should uphold high academic standards. Three legal issues of concern to faculty are addressed: What does fair and equitable treatment entail? What are the due process requirements for academic dismissals? Are negative performance evaluations libelous and defamatory? Recommendations are made to meet legal requirements and to promote academic excellence.

"If at first you don't succeed": using failure to improve teaching.

The authors surveyed a group of distinguished clinical teachers regarding episodes of failure that had subsequently led to improvements in their teaching. Specifically, they examined how these teachers had used reflection on failed approaches as a tool for experiential learning. The respondents believed that failures were as important as successes in learning to be a good teacher. Using qualitative content analysis of the respondents' comments, the authors identified eight common types of failure associated with each of the three phases of teaching: planning, teaching, and reflection. Common failures associated with the planning stage were misjudging learners, lack of preparation, presenting too much content, lack of purpose, and difficulties with audiovisuals. The primary failure associated with actual teaching was inflexibly using a single teaching method. In the reflection phase, respondents said they most often realized that they had made one of two common errors: selecting the wrong teaching strategy or incorrectly implementing a sound strategy. For each identified failure, the respondents made recommendations for improvement. The deliberative process that had guided planning, teaching, and reflecting had helped all of them transform past failures into successes.

The roles of experience and reflection in ambulatory care education.

While ambulatory care education typically does not provide much direct instruction, supervision, or feedback, experiential learning occurs. Using experiential learning theory, the authors describe how this process of learning works. the process is characterized by a cycle of having a concrete experience (e.g., an encounter with a patient), reflecting on that experience as it unfolds, formulating conceptualizations and generalizations from the experience, and testing those generalizations and concepts in other situations. With this model in mind, the authors make four recommendations for improving ambulatory care education for both medical students and residents: (1) plan for experiences in carefully selected ambulatory care settings; (2) facilitate reflective observation; (3) encourage conceptual thinking and inquiry; and (4) promote feedback and testing of insights from experiences. The authors discuss the rationale behind each recommendation and offer guidelines for how each might be implemented.

Strategies for improving teaching practices: a comprehensive approach to faculty development.

Medical school faculty members are being asked to assume new academic duties for which they have received no formal training. These include time-efficient ambulatory care teaching, case-based tutorials, and new computer-based instructional programs. In order to succeed at these new teaching tasks, faculty development is essential. It is a tool for improving the educational vitality of academic institutions through attention to the competencies needed by individual teachers, and to the institutional policies required to promote academic excellence. Over the past three decades, strategies to improve teaching have been influenced by the prevailing theories of learning and research on instruction, which are described. Research on these strategies suggests that workshops and students' ratings of instruction, coupled with consultation and intensive fellowships, are effective strategies for changing teachers' actions. A comprehensive faculty development program should be built upon (1) professional development (new faculty members should be oriented to the university and to their various faculty roles); (2) instructional development (all faculty members should have access to teaching-improvement workshops, peer coaching, mentoring, and/or consultations); (3) leadership development (academic programs depend upon effective leaders and well-designed curricula; these leaders should develop the skills of scholarship to effectively evaluate and advance medical education); (4) organizational development (empowering faculty members to excel in their roles as educators requires organizational policies and procedures that encourage and reward teaching and continual learning). Comprehensive faculty development, which is more important today than ever before, empowers faculty members to excel as educators and to create vibrant academic communities that value teaching and learning.

Protecting time for teaching in the ambulatory care setting.

The current drive for efficient clinical teaching threatens the educational mission of academic medical centers. With pressures to increase clinical productivity, protected time and compensation for teaching have become scarce resources for clinical teachers in all settings. Although it may yield new approaches to education, the push for efficiency may ultimately result in insufficient time for teaching and may cause some clinical preceptors to stop teaching completely. Further, it may lead to the illusion that comprehensive teaching truly requires little time. Since the future of American health care depends upon the provision of high-quality clinical education to young physicians, this situation presents a potential national crisis. In this article, the authors discuss the complex nature of teaching, its time requirements, and the special challenges of teaching in outpatient settings. To avoid overemphasizing efficiency to the detriment of education they recommend adhering to two principles: (1) academic medical centers are educational as well as training institutions, and therefore should provide a broad-based education as well as training in clinical skills; and (2) the clinical teaching process is complex and adequate time must be provided for its many phases, including planning, instructing, and reflecting. Finally, the authors make recommendations for ensuring the delivery of high-quality education in ambulatory care settings.

Education in ambulatory settings: developing valid measures of educational outcomes, and other research priorities.

Efforts to redesign education in ambulatory settings are hampered by a lack of rigorous and coherent research on the learning process in these settings and the desired outcomes of the educational experiences. The authors present 13 priority research topics and 51 important research questions concerning education in ambulatory settings that were defined by a distinguished group of medical educators, clinicians, and policymakers who attended an invitational conference on education in ambulatory settings in 1996. The need to establish valid and reliable measures of quality and outcomes of educational programs and instructional interventions stood out as the major prerequisite for conducting research on education in ambulatory settings. Issues of theory building, research priorities, and research design are discussed, and policy recommendations are made for the development of valid measures of educational outcomes. The creation of a "Medical Education Outcomes Commission" is proposed to act as a repository for measures and instruments, and to provide the field with mechanism to validate instruments and uniform recommendations to conduct studies of quality. The authors urge funding agencies with missions that support medical education to invest in basic research on the outcomes of education in ambulatory settings.

Characteristics of effective clinical teachers of ambulatory care medicine.

This study identified characteristics of clinical teachers in ambulatory care settings that influenced ratings of overall teaching effectiveness and examined the impacts of selected variables of the clinic environment on teaching effectiveness ratings. A survey instrument derived from prior research and observations of ambulatory care teaching was sent to 165 senior medical students and 60 medicine residents at the University of Washington School of Medicine in 1988. A total of 122 (74%) of the seniors and 60 (71%) of the residents responded. Results indicate that the most important characteristics of the ambulatory care teachers were that they actively involved the learners, promoted learner autonomy, and demonstrated patient care skills. Environmental variables did not have a substantial influence on these ratings.

Four exemplary preceptors' strategies for efficient teaching in managed care settings.

To identify time-efficient and educationally effective methods for teaching in ambulatory care and managed care settings, the authors studied four exemplary preceptors who taught family medicine clerks in managed care clinics. They interviewed all four preceptors and observed three of them. All of these preceptors claimed to practice more efficiently with students than without them. Analysis of 33 patients encounters involving students revealed that each of the five students observed spent an average of 12.0 minutes conducting a history and physical examination, 2.2 minutes presenting the case to the preceptor, 7.9 minutes observing the preceptor reviewing and/or repeating the examination with the patient, and 1.8 minutes receiving direct instruction and feedback from the preceptor. The total time per patient encounter was 23.7 minutes, 11.7 minutes of which directly involved the preceptor. The authors then compared these 33 encounters with encounters involving the preceptors alone; these encounters took an average of 10.6 minutes of the preceptors' time. The 1.1-minute difference between the amount of time preceptors spent in encounters involving students and the amount of time they spent in encounters on their own was not statistically significant as measured by t-test (p < .05). However, in calculating this time difference, possible time saved by students' assistance with charting was not accounted for. In interviews the preceptors identified three major instructional strategies for time-efficient teaching; planning and preparing; teaching with patients; and charting, giving feedback, and reflecting. Students described these preceptors as enthusiastic teachers and good role models; however, they also felt that their first two years of education had not prepared them for seeing patients in fast-paced ambulatory care settings. The challenge for medical schools is to better prepare both students and preceptors for learning and teaching in productivity driven ambulatory care and managed care environments.

Faculty development for ambulatory care education.

Faculty play an important role in the delivery of quality instruction in the ambulatory setting. As medical schools and residency programs move more clinical training to ambulatory care settings, more faculty must be recruited and trained. Medical educators have attempted to prepare faculty to teach in ambulatory care settings by conducting faculty development programs. This study documents the current practices of a sample of 14 peer-nominated medical educators who conduct this type of faculty development program. The authors conducted telephone interviews to learn what these educators taught, how they conducted and evaluated their programs, and the theoretical framework guiding their selection of program content and format. Results show that these faculty development programs were delivered almost exclusively in the workshop format, and that there was remarkable similarity in the topics and strategies used. Evaluation was generally limited to satisfaction ratings. Based on the results of this study, the authors recommend that faculty development programs that now emphasize the teaching encounter itself should give equal emphasis to (1) the importance of pre-instructional planning; (2) teaching faculty how to employ post-instructional techniques such as reflection; and (3) training learners and clinic staff to collaborate with faculty in the learning process.

Evaluation of clinical teaching by general internal medicine faculty in outpatient and inpatient settings.

PURPOSE: To determine the measurement characteristics of a form used to evaluate teaching in outpatient settings, and to compare ratings received by general internists in outpatient and inpatient settings. METHOD: The physicians evaluated were 29 faculty who taught in both outpatient and inpatient settings affiliated with the Department of Medicine, University of Washington School of Medicine, over a five-year period (from 1985-86 through 1989-90). Residents completed 639 evaluations, using a six-point Likert-type scale (from 1, very poor, to 6, excellent) to rate instructors in eight categories and to provide an overall assessment of each instructor's teaching effectiveness. In addition, each evaluation contained an indication of the resident's perceived degree of involvement with the instructor. Statistical analysis involved two-tailed t-tests, analysis of variance and covariance, intraclass correlation coefficients, and the Spearman Brown prophecy formula. RESULTS: When more than ten raters of teaching in outpatient settings were available, the reliabilities ranged from .58 to .81. The outpatient-setting ratings were significantly lower than the inpatient-setting ratings for seven categories, overall teaching effectiveness (5.01 versus 5.35, p < .05), and perceived degree of involvement of the instructor with the resident. When controlled for perceived degree of involvement, differences remained in only two categories: demonstration of clinical skills, rated higher for outpatient settings, and instructor accessibility, rated lower. CONCLUSION: The evaluation form provides reliable ratings of teaching in outpatient settings when more than ten raters are available. The differences found in the ratings between the inpatient and outpatient settings may be explained by the factor of the resident's perceived degree of involvement with the instructor.

Development and psychometric properties of the Washington Primary Care Interest Inventory.

PURPOSE: To describe the development of the Washington Primary Care Interest Inventory (WPCII), which was designed to assess attitudes toward what constitutes appropriate psychosocial concerns for visiting a family physician, and to demonstrate the relationship between these attitudes and specialty selection in matriculating medical students. METHOD: Five entering classes of medical students (1990 to 1995, without 1992) at the University of Washington were administered the WPCII during orientation. Reliability, factor, and predictive validity analyses were performed to measure the utility of the WPCII. RESULTS: Factor analysis revealed three interpretable factors to underlie the WPCII: stressors, physical complaints, and familial complaints. Scales developed from these factors correlated with students' early career preferences and showed significant differences across students who were selected under different interviewing formats. Differences between the sexes were found for both specific items and scales. CONCLUSION: The WPCII is a reliable and valid measure of attitudes toward the appropriateness of family physicians' treating psychosocial complaints. These attitudes have implications for the selection of medical students, curriculum development, assessment, and health education research.

Insights from outstanding rural internal medicine residency rotations at the University of Washington.

PURPOSE: Despite being well suited to provide the breadth of care needed in rural areas, few general internists become rural physicians. Little formal rural residency training is available and no formal curricula exist. For over 25 years the University of Washington School of Medicine has provided elective WWAMI (Washington, Wyoming, Alaska, Montana, Idaho) rural residency rotations to expose residents to the rewards and challenges of rural practice. This study identified the characteristics of outstanding rural residency rotations. METHOD: The key preceptors at three outstanding rural residency sites were interviewed about their experiences, teaching strategies, and opinions about curriculum. Their responses were categorized. Seven university-based residents and eight training at WWAMI sites recorded and rated the value of over 1,500 learning encounters. RESULTS: The preceptors agreed that outstanding rotations were led by enthusiastic preceptors who served as role models for excellence. These preceptors provided residents with meaningful responsibilities and emphasized independent decision making based on the history and physical examination. They stressed supervised independence and self-directed learning with frequent structured feedback for residents. The residents rated the learning value of patient encounters in rural locations significantly higher than that of those in university clinics. CONCLUSIONS: Exceptional rural residency experiences involve excellent role models who provide meaningful responsibility and emphasize core skills using a learner-centered approach. Rural training experiences should be supported, and the suggestions of outstanding preceptors should be used to develop and disseminate a curriculum that will better prepare residents for rural practice.

Precollege enrichment programs intended to increase the representation of minorities in medicine.

The authors reviewed the literature published from 1966 to 1996 to identify enrichment programs for underrepresented minority precollege students sponsored by medical schools and affiliated programs, finding 19 articles describing 27 programs. The authors categorized the reported programs according to the components they contained. Most programs contained more than one component type. Twenty-four programs had an academic enhancement component. Two thirds had a motivational component to encourage students to consider medical and other health careers. Two programs set up mentoring relationship between students and health professionals. There were four research apprenticeships and three academic partnerships between medical schools and local school districts. Twelve of the 27 programs were evaluated in the literature. Eight evaluations focused on identifying the numbers of students who continued their education into college and professional schools. Five programs reported participant satisfaction or identified other short-term outcomes such as gains on standardized tests. While the percentage of participants completing college and entering health care careers is impressive, the authors do not believe that the educational success of participants can be attributed to involvement in these programs. The authors recommend ways to improve the quality and interpretability of enrichment program evaluations. Evaluators should adopt common terminology for activities and outcomes. Participants' economic and educational disadvantages should be described. Programs' theoretical underpinnings should be identified and related to evaluation. Measures should include immediate effects as well as long-term outcomes. Where possible, data from comparison groups should be reported to support conclusions. Adequate funding needs to be available to design and complete reasonable evaluations.

Role models' perceptions of themselves and their influence on students' specialty choices.

PURPOSE: To examine the perceptions of faculty role models to learn whether their perceptions of role models' behaviors are congruent with those of their students. METHOD: In 1996 a survey was mailed to 210 student-identified faculty role models at the University of Washington School of Medicine and the University of North Carolina at Chapel Hill School of Medicine. The nominees were asked to rate to what extent each of 32 student-identified role model characteristics was representative of their behavior. They were then asked to rank order the characteristics they felt were most important to model for students. The role models were also asked to rate how much influence they perceived themselves to have on their students' specialty choices. A final, open-ended question inquired about the single characteristics they modeled to students that most influenced the students' specialty choices. The role models' specialties were grouped as either primary care (PC) or non-primary care (NPC). Data were analyzed with several statistical methods. RESULTS: Of the 210 mailed surveys, a total of 177 were returned, for a response rate of 84%. The role models perceived their behaviors much like their students did; the role models' self-ratings were generally high for all of the student-defined characteristics. Although clinical reasoning was considered the most important characteristic to model for students, the role models also believed that enthusiasm and love for their work were the characteristics that most influenced their students' specialty choices. Few differences were found between the PC and the NPC role models. CONCLUSION: The role models in this study agreed with their students about what is important to model. They did not intentionally try to recruit students to join their specialties but felt that demonstrating enthusiasm and a sincere love for what they did has a strong influence toward this end.