Effective Clinical Teaching on Rounds: Microskills Worth Practicing

A group of multi-ethnic doctors in a hospital room, wearing white lab coats, having a discussion. Two of the female doctors are holding digital tablets.

By Martina M. McGrath, MD
May 24, 2017

On-the-job clinical teaching of students and physicians in training is a central aspect of medical education. For trainees, skilled teachers can become mentors and role models; often inspiring them choose a particular specialty and also having a formative influence on their clinical practice. For the teacher, it can be one of the most rewarding and enjoyable aspects of their practice. However, due to the frenetic nature of the clinical work environment with many competing demands, clinical teaching is frequently rushed, disjointed, and interrupted. Most of us would like to be better teachers, but how do we best make use of our limited time to impart some clinical pearls and support our trainees in their professional development?

Using a structured approach to teaching during a clinical encounter can maximize the learning opportunity without placing excessive burden on busy clinical teachers. Many approaches have been proposed but one of the more appealing ones, due to its simplicity, is The One minute preceptor: Microskills model of clinical teaching as proposed by Neher.1 This model distills a large body of learning theory into a manageable, five-step approach to a clinical teaching encounter:

Step 1: Get a commitment:  “What do you think is going on?”
Encouraging the trainee to commit to a diagnosis/plan of evaluation helps them to synthesize their thoughts and focus on the question at hand. Committing also helps them recognize their own learning needs, which encourages self-directed learning.

Step 2: Probe for supporting evidence: “Why do you think that?”
At this point, the temptation on the part of the teacher is to simply provide the correct answer or begin an explanation. However, encouraging active participation by the trainee will give them a much better learning experience. The aim is to encourage the trainee to reflect and work through the problem. This will in turn allow the teacher to provide more directed instruction related to the trainee’s level of knowledge and expertise.

Step 3: Teach general rules
Teaching is frequently more transferable and applicable when provided as general rules.1 An approach such as ‘when this happens, do this…’ can be very helpful. Having encouraged the trainee to work though the problem will allow the teacher to appropriately target this information to the trainee’s level.

Step 4: Reinforce what was done correctly
Feedback, which is specific to the task at hand and delivered in a timely manner, is an important way to reinforce learning. As many trainees are still developing their professional identities, reinforcing positive professional attributes also encourages their personal development.

Step 5: Correct Mistakes
Many teachers struggle to give negative feedback. Encouraging the trainee to reflect on his or her own performance is a nonconfrontational way to open the discussion of any errors that were made. Similarly, criticism should be of the approach rather than the individual (‘this aspect of the case could have been better dealt with by xx…’ as opposed to ‘you handled this case badly’).

Informal, opportunistic teaching is a central component of medical education. Applying an outline structure can improve the efficiency and effectiveness of a given teaching opportunity. By encouraging a discussion rather than a lecture, this type of approach can give educational benefit, and more enjoyment, for both the learner and the instructor.

References:

  1. Neher, et al. A Five-step “Microskills” Model of Clinical Teaching. Journal of the American Board of Family Practice. 5:419-424, 1992.

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Headshot of Dr. McGrathDr. Martina McGrath is an Instructor in Medicine at Harvard Medical School, and a member of the Renal Division, Department of Medicine, at Brigham and Women’s Hospital, both in Boston. Dr. McGrath is the Medical Editor for the Trends in Medicine blog.

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