Teaching in Clinical Settings

Thank you for serving as a clinical faculty member for the Herbert Wertheim College of Medicine at Florida International University. We are grateful for your time, resources, and energy in educating our students at the site of clinical care and trust that educating the next generation of physicians will contribute to your professional satisfaction.

This website contains teaching ideas to help you work with students in the clinical setting. It also contains specific information on our overall curriculum and earning CME for learning more about teaching. The clinical skills that allow you to be an excellent clinician can also empower you to be an excellent educator. Consider those who educated you – who do you wish to emulate? What skills made them so effective as medical educators? In what ways did those medical educators impact your growth, your decisions, your practice as a physician, and your current life? As an educator, you will also influence the lives of the students you teach and the patients your learners will one day care for.

Teaching does take time; this website hopes to detail options for enhancing your teaching while optimizing your valuable time, such as orienting learners to your clinical site and your expectations. For example, communicating your expectations around pre-rounding details or pre-clinic huddling can focus the student’s energy into integral patient care roles so that they add value to patient care.

What do patients think of working with medical students? Many patients have enhanced satisfaction in their physician interactions when accompanied by students. Patients may value their roles as teachers and come to expect that students will be on your in-patient team or outpatient clinic. Communicating to patients that you will see the patient and introducing the student is helpful in reassuring patients.

As clinical faculty, you facilitate the students’ richest and most meaningful learning – taking care of patients. Our curriculum relies on you, as clinical faculty, to help our students discover and cultivate the knowledge, skills, and attitudes that will make them better physicians. We appreciate your work in delivering our innovative curriculum aligned with the latest standards of medical education.

With our best regards,
Suzanne Minor, MD, FAAFP

  • Orienting the Learner to the Site and Preceptor

    Orienting students and setting expectations are the foundations of a good clinical learning experience. Skilled clinical teaching will be lost on a student who is preoccupied with trying to figure out what they should do, what they are supposed to learn and know, what and how much they are supposed to do with a patient, or even how they will find the bathroom.

    In some sites, ancillary providers or staff may quickly provide this on the student’s first day. If you would like to write any specific and consistent expectations of your site for students to review prior to the first day, the clerkship director or clinical faculty director can provide this before the rotation begins. Some clinical sites may provide an “Orientation PowerPoint” the students can watch prior to arrival at the site. If you would like to do this with narration, FIU has very easy-to-use PowerPoint narration software provide by the IT support staff.

    The One Minute Learner is a tool adapted from Boston University that you can use when you first meet the student to orient them to your teaching and site:

    ONE MINUTE LEARNER, adapted from Boston University

    1. GOALS: Learner’s level of experience; Learner’s and Your Goals
    2. GETTING GOING: When, how and who should the learner see?
    3. HOW MUCH and HOW LONG Focused or Full?
    4. PRESENTING: Where and how?
    5. CHARTING: When and how?
    6. QUESTIONS: When is a good time to ask questions that come up?
    7. USE OF TECHNOLOGY* When can learners use phones/ipads to look up the answers to clinical questions? At the moment of care or later?
    8. UNSTABLE PATIENTS* How would you describe an unstable patient? When should the learner immediately get you to assess a patient?
    9. LOGISTICS* who’s on the team/reporting/residents, the logistics of rounds, lunch, bathroom, entry codes, daily schedule/activities/roles for student (even if faculty not on floor)

    *added by S.Minor at FIU

    For further information about the One Minute Learner, click here:

    You can also ask your staff to orient the students to:

    • How patients move through the wards and hospital
    • How the student may contribute to patient care
    • How to contact the hospital team in case of personal emergency
    • Where to put personal belongings and any possible independent workspace
    • Rooms equipment, supplies, and organization
    • Patient education materials
    • EMR Access
    • Retrieving test results
    • Ordering tests and consultations
    • Scheduling follow-up appointments
    • Dining options and locations
  • Clinical Teaching

    This 17-minute voiceover PowerPoint describes clinical teaching:

    In this article, resident evaluation comments were reviewed for effective teaching in anesthesiology; these behaviors are likely applicable across specialties and for teaching medical students as well. Scroll down to Table 5 which details 13 concrete behaviors of effective teaching of residents:

    1. Support teaching with primary literature
    2. Explain your clinical decision-making
    3. Make an effort to spend additional time teaching, make teaching a priority
    4. Make clinically relevant teaching a priority
    5. Give autonomy as appropriate; maintain appropriate supervision always
    6. Challenge your residents to a higher level of performance
    7. Be patient and supportive while teaching a new procedure
    8. Encourage the use of new methods of procedures
    9. Maintain your clinical practice (both skills and knowledge)
    10. Give clear, constructive, and developmental feedback
    11. Treat the resident collegially and respectfully
    12. Be gentle when providing criticism; never criticize a resident (learner) who isn’t present
    13. Avoid displays or expressions of frustration, anger, or impatience; provide criticism in an appropriate manner, at the appropriate time

    Article Citation: Haydar B, Charnin J, Voepel-Lewis T, Baker K. Resident characterization of better-than-and worse-than-average clinical teaching. Anesthesiology. 2014 Jan;120(1):120-8. doi: 10.1097/ALN.0b013e31829b34bd. PMID: 23838713.

  • Teaching Clinical Reasoning

    In this article, authors interviewed clinical educators on best practices for teaching clinical reasoning. The authors detail 4 ways that exemplary attendings teach clinical reasoning:

    1. Emphasizing organization and prioritization
    2. Accessing prior knowledge
    3. Thinking aloud
    4. Analyzing the literature

    Read the full article for multiple examples or scroll down to Table 2, which sums up these themes with specific examples and is the take away from this article. The link above brings you to a full text, free link.

    Article Citation: Houchens N, Harrod M, Fowler KE, Moody S, Saint S. How Exemplary Inpatient Teaching Physicians Foster Clinical Reasoning. Am J Med. 2017 Sep;130(9):1113.e1-1113.e8. doi: 10.1016/j.amjmed.2017.03.050. Epub 2017 Apr 26. PMID: 28454903.

  • Teaching at the Bedside

    The inpatient physician functions as an educator and as a coach. From the outset, set expectations of the learner using the One Minute Learner. Consider the structure of your rounds. Let the student know how many patients he/she is responsible for pre-rounding on, what to do during pre-rounds, and the time/location/structure of rounds.

    The inpatient attending can motivate learners by addressing learners by name, using physical touch, tapping into the student's own motivation for learning (personalize your teaching based on the student’s interests or motivations), using visualization, emphasizing methods rather than content, and striving to ensure the quality and quantity of teaching as appropriate to the level of the learner. You do not have to know everyone’s name to start with. Call on the learner whose name you do know and ask them to call on the next person: "Gregoir, I've called on you enough. Choose someone else on the team by name." Use the names as often as you can to remember them.

    To promote learner memory and retention, the attending should:

    • Consider using organizers (such as illustrations or mnemonics) and teaching in an orderly sequence (building on foundational information).
    • Using questions appropriately (see the section on using questions) can help students to learn as well.
    • Teaching in the Presence of the Patient (TIPP) can be helpful to involve the patient, role model patient-centeredness, and further your own work satisfaction. To learn more about TIPP, view either of these resources: stfm.org

    Another important task for the attending is to establish a supportive environment in which everyone can say “I don’t know”, even the teacher. This can also be considered a no-blame culture. Calling on students during rounds with questions regarding patient care and management is appropriate in that your motivation is to further patient care and student learning. Calling on a learner until they don’t know a question that seems unrelated to patient care may be perceived as pimping and will not further the student’s learning. The same skills that you use in communicating with patients will help you to communicate with students. Rounds present an excellent opportunity to ask questions linking the learner’s basic science knowledge to clinical care and treatment.

    In the inpatient setting, learners can hone their time management, data organization, interpersonal, communication, lifelong learning, and clinical skills. Students may not understand how to address the many tasks they will be charged within the inpatient setting. You may encourage learners to organize their tasks into important or urgent tasks and prioritize urgent tasks. Assigning learner reading to be presented at the end of the day or the following day will help the student to incorporate daily reading into her/his daily habits.

    This article discusses "Twelve tips to improve bedside teaching"

    These YouTube videos offer tips on teaching at the bedside:

  • Teaching in the Outpatient Clinic

    This is a brief summary of "How to Be an Efficient and Effective Preceptor" from Family Practice Management:

    This 3-page article from the Society for Teachers for Family Medicine describes "Strategies for Efficient Office Precepting."

    This short article describes "How to Be an Efficient and Effective Preceptor" and is from Family Practice Management.

    The University of Western Australia crafted the Teaching on the Run Tips Series. Each Tip is less than two pages.


    This 17 minute voice over powerpoint describes clinical teaching:

    Clinical Teaching

  • Teaching in the Operating Room

    The operating room is a profoundly rich learning environment for students when faculty and staff take simple steps to help students navigate through their initial sense of intimidation and disorientation, while setting some basic expectations for learning and preparation.

    Preparing for the Case

    While a surgical resident can be directed to "read about the case" or "review the procedure" the night before, a medical student will benefit from more specific direction, such as "read about the muscles and vasculature of the anterior abdominal wall" or "review the course of the ureter in the pelvis." When possible, they should read or review a video prior to the case, which at least begins at their level. FIU students are given links to several websites with surgical videos. Let them know of any you strongly recommend for early learners - ones that break cases into the major steps with reference to the most relevant aspects of anatomy for that case.

    Students should of course know the patient when possible, and if not, know the key details of the case. Especially since the emphasis for third-year learning is diagnosis, it is important for them to understand how the patient’s surgical disease presented, the differential diagnosis for that presentation and the work-up for that presentation.

    Regarding informed consent, you can help the student understand:

    • What is it that the patient needs to make the right decision?
    • How do you know if someone really understands the risks and indications?
    • Here is what I do to understand the situation from the patient’s point of view . . .
    • Here is how I deal with my biases . . .
    • Here is what I do to mediate when the family disagrees over care . . .

    In the Operating Room

    Especially the first few times in the operating room, and the first time with a new attending, students need communication and cues. Let them know:

    • If they will scrub or just observe
    • Where they should stand
    • What they will/might do (i.e., place a foley, close skin, put on a tenaculum)
    • When they might get to see the operative field on open cases

    Use anatomical terms to describe location.

    It is also important to remember that when instructing students in instrument, retractor, and suture placement and movement, terms like "up" and "down", or "here" or "there", can be very confusing. They are usually better replaced with anatomical terms (e.g., anterior abdominal wall, caudad, the patient’s right side).

    Use ancillary staff

    Students can learn from others in the OR as well. Spending a portion of the case with a scrub nurse who names the instruments as they are passed, while offering a basic description of how that instrument will be used, may be a better learning experience than simply retracting in a field that they cannot see.

    Remember the power of narration.

    Explaining both what you are doing and why you are doing it, will turn for many students a bewildering and passive experience into a goldmine of learning by observation.

    Let the students know.

    Students need to hear both what they are doing well ("You cut the structure the correct length") and what they need to correct ("You need to close the instrument completely").

    Resources

    This diagram on teaching medical procedures is from an article from the New England Journal of Medicine geared towards residents who teach and are applicable to any medical educator. 

    This article from the American College of Surgeons describes "Employ a Structured Approach to Teaching Psychomotor Skills to Enhance Learner Performance"

    This 2 ½ page article is from the Association of Professors of Gynecology and Obstetrics and describes "Effective Operating Room Teaching"

  • Giving Feedback

    Giving feedback is an integral skill for medical educators. Characteristics of quality feedback include:

    • Frequent
    • Timely – don’t wait too long!
    • Named – "I'm giving you feedback…."
    • Limited – in bite size chunks, just as we provide patient education
    • Requires a credible source and a culture of respect and support - It’s all about the relationship! Learners need to know you are looking out for their learning and well-being.
    • Based on direct observation
    • Uses questions, thus promoting self-reflection. Some great questions include:
      • "What did you do well?"
      • "What can you improve?"
      • "What’s your SMART plan for improvement?" SMART=Specific, Measurable, Achievable, Relevant, Time-limited
    • Focuses on the process not the person – giving feedback about the process of learning or development of a skill creates a growth mindset whereas feedback about the person creates a fixed mindset in which growth does not occur. This is an example of feedback on the process: "You took in the feedback I gave you about avoiding medical jargon and used layperson’s language when explaining the patient’s diagnosis. Well done!" This is an example of feedback on the person, which is not helpful to the student: "You are such a smart student."

    Giving Feedback: The University of Western Australia crafted the Teaching on the Run Tips Series. Each Tip is less than two pages.
    Giving Feedback for free CME: FIU COM Online Teaching Modules on Giving Feedback for free CME!

    Feedback Pitfalls: Feedback conversations are prone to common pitfalls due to our own behaviors and to the behaviors of feedback recipients. This AM Last Page presents ways to prevent potential unintended negative consequences during feedback conversations.

  • Ways Students Can Contribute to Patient Care While Learning

    Students can contribute to patient care! Consider these opportunities for students to practice their skills while enhancing patient care:

    • Help the nurse with triaging patients.
    • Complete initial intake of patients; this helps patients feel they are waiting less.
    • Complete pre-op history and physical examinations. Then, present these history and physical examinations along with the pre-op labs.
    • Review the EMR on the patient and present to the attending.
    • Track down or follow up on missing lab results/studies.
    • Write patient notes. This may include daily care notes for the chart which you co-sign or discharge summaries which you use for dictating.
    • Present information from evidence-based resources such as Uptodate or a review article from Pubmed.
    • Call consults or act as connection with other health providers.
    • Call the patient with their lab results, further patient education (such as titrating insulin up), and for follow up on behavior changes (such as smoking cessation).
    • Document patient calls.
    • Provide patient education about diet, exercise, family planning and advance directives.
    • Perform injections, blood draws, EKG’s and urine dipsticks.
  • Solving a Teaching Problem

    The Solving a Teaching Problem, by the Carnegie Mellon University Eberly Center, is a quality resource for helping you work with teaching challenges. Even though this resource is geared towards classroom teaching, it’s really useful for clinical teaching!

    For instance, you may be challenged with the question “What do I do when the student doesn’t ask for help when they need it?” This webpage gives several options under that heading which you can click, for example “Student overestimates their ability.” Then, the webpage offers strategies to work on this particular issue.

  • FIU COM Online Teaching Modules for Free CME!

    Go to the FIU COM Online Teaching Modules on Giving Feedback, Narrative Comments, Orientation to Clerkship Teaching, the EPA’s (Entrustable Professional Activities) and the Patient Role in Teaching: