What makes a good clinical educator?

In this constantly evolving world of learner competencies, assessments, and milestones often is forgotten the important role of clinical teachers. We can all remember clinical instructors that stand out despite the grueling years of medical school and residency training. We admired them for various reasons and remember the insights and teaching pearls they bestowed upon us. But what exactly were the qualities that they possessed that other instructors did not have? What exactly did they have that made them a good clinical teacher in medicine?

Good Clinical Educator

The authors of the 2008 Academic Medicine paper “What makes a good clinical teacher?” wanted to know exactly that [1]. And so they did a qualitative analysis of 68 articles, essays, and public addresses published from 1909-2006 . Surprisingly, they found that those qualities listed more often were noncognitive skills although cognitive skills were definitely highly considered.
Noncognitive skills were defined as relationship skills, emotional states, and personality types. Examples of this included those instructors who were inspiring and motivating – encouraging learners to be the best that they could be. Cognitive skills were defined as those involving perception, memory, judgment, reasoning, and procedural skills. An example would be good medical decision making for patients with chest pain.
The most common themes the authors found to be present in good clinical teachers in medicine included:

1. Medical / clinical knowledge
2. Clinical and technical skills / competence, clinical reasoning
3. Positive relationships with students and supportive learning environment
4. Communication skills
5. Enthusiasm

The authors best summarized their findings as

“excellent teaching, although multifactorial, transcends ordinary teaching and is characterized by inspiring, supporting, actively involving, and communicating with students”.

The authors conclude there must be a recognition of the importance of noncognitive skills in those who want to improve as clinical educators. Although the medical knowledge is important, that is merely the standard by which all educators must have. But to excel requires inspiring and motivating.
What are your thoughts regarding this paper? Think back to those educators that you had that made a lasting impact? What was it about them that made them so special? Do you agree with this list of attributes above? Or do you have anything that you would add or detract?

“I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”
- Maya Angelou

Expert Peer Review

Outstanding clinical instruction is vital to a learner’s growth and development. Many qualities of outstanding instructors, identified in Sutkin’s article [1] and elsewhere [2-4], help educators in or outside the emergency department be successful. Didactic sessions and lectures in a conference room or auditorium, simulation, journal club, or podcasts are better with great instructors. Bedside teaching offers one venue for emergency physician educators. Despite knowing that good clinicians aren’t always great instructors, Niki labeled Sutkin’s as “Good clinician”. 
Where teaching takes place, its purpose and the audience matter. Formal teaching rounds by internal medicine faculty in a conference room to a team of learners at various levels without interruption rarely matches the style of, and opportunities for, teaching in the ED. Mandatory morning lectures to tired, hungry, distracted, or disinterested residents provide teaching opportunities without interruption, but infrequently deliver content in a manner that fosters integration and retention [5-10].
Bedside teaching is not without problems too. One example occurs when a learner presents a patient and the instructor focuses on the neurologic examination rather than the organ system responsible for the patient’s condition. The instructor may be an expert in neurology, therefore preferring to direct all learning towards his strength. This affords him comfort, and allows him to demonstrate his expertise. If you were to ask the instructor whether or not his teaching was effective, his answer would be an emphatic “yes.” Sadly, however, what the learner needed was teaching about the GI and cardiac systems responsible for the patient’s symptoms. The learner likely didn’t appreciate the instructor’s neurology expertise at that moment. Consequently, the learner considers the teaching to be poor.
As instructors, we must pay attention to our lesson, its appropriateness for the situation, and to the learner (and therefore, the patient). Furthermore, learners are better able to apply material that is relevant to their current educational demands, and are therefore more likely to retain this knowledge over time. Focused teaching creates a better “result” from their perspective.
Outstanding instruction requires practice. It requires a strong (not encyclopedic) fund of knowledge. Often individuals who know “everything” about a topic are not good teachers because they fail to translate their knowledge in a manner that allows learners to integrate new facts, skills, and reasoning abilities into something they not only can recall, but also apply. These shape the competencies, proficiencies, and milestones getting so much attention.
The key is to approach teaching in ways that acknowledge both the learner and the context. Most agree that poor teaching is better than no teaching. Yet outstanding instruction requires passion, commitment, integrity, and strong noncognitive skills. It should go without saying that making stuff up is never a good idea, may be dangerous, and can result in a teacher losing credibility rather than impressing learners.
Good listening skills are important to good clinical teaching because they allow an instructor to discover what learners desire to learn, how they think, and how much they truly understand. As instructors, we can engage learners by asking questions, soliciting input, and identifying whether or not they understand our message. It always helps me to remember that the success of learners equates to successful instruction.
Good teachers remember to teach to learners, not at them. They make their content interesting and teach with enthusiasm. They don’t focus only on their own strengths, but also on their learners’ needs. Our patients provide plenty of wonderful material for teaching. All patients have a story. These stories (some more interesting than others) offer instructors “teachable moments.”
Many terrific resources exist about clinical teaching [11-19].Here are a few pearls:

• Adapt teaching to your audience, the environment, and the context
• Teach to (or with) your learners, not at them
• Be patient
• Have a plan
• Listen well and ask questions to engage your learners
• Be as prepared as possible whenever possible
• Limit the number of key messages
• Admit what you don’t know and be comfortable looking things up
• Demonstrate sensitivity to, and respect for, your learners and their time
• Take advantage of a teachable moment

These pearls should help teachers be better. You know what? These qualities are similar to the qualities that make a good clinician. Maybe Niki was right.

Gus Garmel, MD FACEP FAAEM, Clinical Professor (Affiliate) of Surgery (EM), Stanford University School of Medicine, Former Co-Director, Stanford/Kaiser EM Residency Program, Senior EM Faculty, TPMG, Kaiser Santa Clara, CA, Consultant to Regional GME, Kaiser Northern CA, Oakland, CA, Senior Editor, The Permanente Journal, Portland, OR

References

1. Sutkin G, Wagner E, Harris I, Schiffer R. What Makes a Good Clinical Teacher in Medicine? A Review of the Literature. Acad Med 2008;83:452-66.
2. Wright SM, Kern DE, Kolodner K, et al. Attributes of Excellent Attending-Physician Role Models. New Engl J Med 1998;339:1986-93.
3. Avegno J, DeBlieux PMC. Characteristics of Great Teachers. In Practical Teaching in Emergency Medicine. Rogers RL (ed). Wiley-Blackwell. UK. 2013:285-94.
4. Bandiera G, Lee S, Tiberius R. Creating Effective Learning in Today’s Emergency Departments: How Accomplished Teachers Get it Done. Ann Emerg Med 2005;45:253-61.
5. Kerr C. Death by Powerpoint: How to Avoid Killing your Presentation and Sucking the Life out of your Audience. ExecuProv Press. Santa Ana, CA. 2001.
6. Skeff KM, Stratos GA, Mygdal W, et al. Faculty Development: A Resource for Clinical Teachers. J Gen Intern Med 1997; 12(Suppl 2):S56-S63.
7. Skeff KM, Stratos GA. Methods for Teaching Medicine. ACP Press. Philadelphia, PA. 2010.
8. Shulman LS, Hutchings P. The Wisdom of Practice: Essays on Teaching, Learning, and Learning to Teach. Wilson SM (ed). Jossey-Bass. San Francisco, CA. 2004.
9. Ende J. Theory and Practice of Teaching Medicine. ACP Press. Philadelphia, PA. 2010.
10. Guth TA. Resident as Educator: A Guidebook Written by Residents for Residents. EMRA. Irving, TX. 2013.
11. Cooke M, Irby DM, O’Brien BC. Educating Physicians: A Call for Reform in Medical School and Residency. Jossey-Bass, San Francisco, CA. 2010.
12. Kelly SP, Shapiro H, Woodruff M, et al. The Effects of Clinical Workload on Teaching in the Emergency Department. Acad Emerg Med 2007;14:526-31.
13. Thurgur L, Bandiera G, Lee S, Tiberius R. What do Emergency Medicine Learners Want from their Teachers? A Multicenter Focus Group Analysis. Acad Emerg Med 2005;12:856-61.
14. Whitman N, Schwenk TL. The Physician as Teacher, 2^nd ed. Whitman Associates. 2007.