Strengths of Clinical Education
Student satisfaction with clinical teaching reflects not only the strengths of clinical teachers but also the positive aspects of clinical education itself. Clinical education has three distinguishing, positive characteristics:
(a) a problem-centered approach in the context of professional practice,
(b) an experience-based learning model, and
(c) a combination of individual and team learning.
 

The focus of clinical education is on the patient. Patient problems provide teaching opportunities for the faculty and learning opportunities for the student. The richness of that learning experience depends in large measure upon the faculty member's instructional skills and the patient mix available. Since clinical instruction takes place in the context of professional practice, student questions about the relevance of what is to be learned are minimal and motivation is high. The students actively strive to emulate faculty and resident role models.

        Another major strength of clinical education is the combining of individual and team learning. While students are responsible as individuals for their learning during a clinical clerkship, this learning experience is in the context of the work team. Instructional time and effort are allocated in the context of teamwork and team function. In a field study of instruction by attending physicians in an internal medicine department, Mattern, Weinholtz, and Friedman (4) observed that learning by individual team members appeared tied to overall team development. As individual team members learn, they appear better able to contribute and use the contributions of others to their teams, and as teams develop their abilities to work together, they appear to promote additional learning among their individual members.
         Clinical education is a challenging experience for most students because it allows them to participate actively in the health care team, seek solutions to real problems and learn by doing while caring for patients.

Clinical education is a conceptually sound learning model which, unfortunately, is flawed by problems of implementation. Some of the more glaring problems of clinical teaching include
(a) limited emphasis upon problem-solving,
(b) lack of clear expectations for student performance,
(c) inadequate feedback to students, and
(d) inappropriate role models and clinical settings.

        One of the persistent complaints about clinical education is the overwhelming work demands placed upon students. This leaves them little time for thinking and reflecting. Eichna, who returned to medical school as a full-time student after a career in medicine, made the following observations about what he experienced (5)
        There is no time to think, to wonder just time to memorize facts. The clinical years perpetuate non-thinking. Inordinate amounts of time are spent in mechanical "doing". Operating-room work, repetitive ward rounds, and nights and weekends an only leave little time for thinking. Fatigue, somatic and cerebral, dulls the thinking and the edge of thought. It is a mistake to hold that bedside teaching is necessarily equated with thinking and problem solving. Some undoubtedly is, but so much of it is mini-lecturing, noneducational chores and the reflexive ordering of test after test.
        Students rarely have an opportunity to reflect on their learning, make connections to basic science information, restructure the knowledge that they already have, and engage in real problem-solving on patients under their care.
 In order for students to learn problem-solving skills, they must actively participate in the learning process. However, there is evidence to suggest that students are not active participants in clinical education. In a study of faculty, resident, and student interactions in one medical clerkship, Foley and associates (6) found in a variety of clinical teaching situations that students participated verbally less than either residents or faculty members. When students were asked to participate, they were primarily asked questions requesting them to supply factual information, usually concerning data from the patient's chart. Very few questions required students to discuss their reasoning, propose alternatives, or suggest implications for action. This is precisely the problem which the report of the Project Panel on the General Professional Education of the Physician (7) addressed in its recommendation that students "be active, independent learners and problem solvers, rather than passive recipients of information."

Another problem with clinical teaching is the lack of clear expectations for student performance. Few clerkships have clearly defined objectives and descriptions of work responsibilities. As a result, students encounter differing and sometimes conflicting expectations for their behavior. Each student tends to have a different educational experience with respect to the information learned and the proficiency of skills developed. These differences occur, in part, as a result of the assigned cases, which tend to be highly unpredictable, as found in a survey commissioned by the Association of American Medical Colleges for the Panel on the General Professional Education of the Physician in 1982.
 Students frequently complain about the lack of feedback on their learning and performance. In student ratings of clinical teaching at the University of Washington School of Medicine, the lowest rated item is usually "Provides Direction and Feedback." This situation is not unique to the University of Washington. Although feedback on their skills and abilities is essential for efficient and effective learning, students often experience clinical clerkships in a feedback vacuum. Feedback from written evaluations of their performances is as inadequate as oral feedback, due to the lack of specificity by faculty members in identifying their students strengths and weaknesses.

The role models and clinical settings to which students are exposed are not always appropriate for the general professional education of the physician. Many faculty members and residents fail to serve as exemplary role models when they fail to attend to the psychosocial needs of patients and the ethical issues of patient care. The teaching sessions over which they preside, particularly word rounds, are frequently haphazard, mediocre, and lacking in intellectual excitement (8).
 This problem is compounded by the use of tertiary care, high-technology medicine in university teaching hospitals where students are exposed to very sick patients. Few opportunities are made available to students on ambulatory and primary care services where routine cases are followed.

Faculty members and residents serve as professional role models and mentors for students. The modeling process should be a purposeful activity that demonstrates the knowledge, skills, attitudes, and ethical behaviors that students should acquire. Students need opportunities to observe role models in action and to study the behaviors that constitute their effectiveness. Role-modeling is a powerful teaching technique and one especially well suited to the apprenticeship system of instruction in medicine. Muslin and Thurnbald (10) describe the role modeling process in psychiatric education: "The trainee learns to approach data with the supervisor's eyes, eats, and sensitivities. This is the learning mechanism involved, an attempt to approach the supervisor's cognitive and empathic styles... Ideally the student takes from the supervisory process not only certain knowledge and understandings but certain partial identifications."

 To be an intentional role model requires the ability to articulate the mental process that led to the successful completion of a diagnosis or clinical procedure. In a study of clinical medical education, Reichsman (8) found that students were generally exposed only to the instructor's solution process that led to that solution. Role-modeling requires that a teacher demonstrate a skill being demonstrated; and discuss the criteria by which the outcome was achieved. This process enables the learner to imitate more effectively that behavior.

 Another aspect of role-modeling is the demonstration of clinical competence. Much of the attending physician's credibility is established by demonstrating such competence. The health care teams' perception of the attending physician's clinical credibility is influenced by the physician's ability to demonstrate effective history and physical examination skills, discuss recent advances in the field, demonstrate effective patient interaction skills at the bedside, and model decision-making skills in group discussions. This ability to establish clinical credibility was found to have a significant impact on the overall instructional influence of the attending physician (4).

 Modeling also involves demonstrating exemplary professional characteristics. These include the noncognitive dimensions of professional practice such as showing genuine concern for patients, recognizing one's own limitations, showing respect for others, taking responsibility, and not, appearing arrogant (9). Students quickly discern the codes of conduct and acceptable behavior of the health care team and act accordingly. If patients are treated with respect and genuine concern by the attending physician and the residents, students will do the same. The reverse is also true.
 The ability to change attitudes and values of students has been debated extensively. Bentler and Speckart (11) have shown that behavior is influenced by attitudes, group norms, prior behavior, and intentions (what the individuals expect they will do). In a study of moral reasoning and physician performance, Sheehan and associates (12) found that moral reasoning was linked to physician behavior in a manner consistent with Bentler and Speckart's model. Both studies found that attitudes and moral reasoning influenced performance while intentions performed a negligible role. Using these findings, Sheehan (13) recommended various intervention strategies to change attitudes and to raise the level of moral reasoning of medical students: (a) attending physicians can exert leadership by setting the moral tone of the organization; (b) they can change the group norms of the health care team; (c) they can help students encounter ideas and conflicts that require struggle and challenge at a level commensurate with the student's ability.
 Students need an environment in which their beliefs, attitudes, and behaviors can be observed, analyzed, and challenged. Attending physicians need to recognize that they are dealing with a mutually reinforcing network of attitudes and behaviors that are amenable to change only through concerted effort.
 Another characteristic of excellent clinical teachers and outstanding role models is their enthusiasm for the practice of medicine and for teaching. They tend to be dynamic, energetic individuals with an infectious enthusiasm that comes from self-confidence, excitement about medicine, and pleasure in teaching (9). The apparent impact of enthusiasm on students is to capture their attention, stimulate further thinking, and infuse the learning environment with energy. Enthusiasm has been found to correlate with student learning gains in several studies.
 Role-modeling is the primary teaching strategy of clinical education. Faculty members demonstrate clinical skills, model and articulate expert thought processes, and manifest positive professional characteristics. Through this modeling process, student knowledge, skills, and attitudes can be changed profoundly.
 

Attending physicians and chief residents are responsible for ensuring that excellent patient care is provided to the patients on their service. As part of that responsibility they must also teach medical students and junior house staff members. The clinical supervisory skills required include providing structure to work and learning, promoting problem-solving and critical appraisal skills, observing and offering feedback on student performance, and providing professional support and encouragement.
 Structuring work and learning environments is a key component of a clinical supervisor's responsibility. This involves clearly articulating expectations, structuring time for learning (as well as work), and providing appropriate practice opportunities. Students are more likely to achieve the intended learning outcomes if they are told clearly what is expected and why. Also, they can better target their attention on the important details and skills to be learned when the learning experience is focused. Maintaining focus and clarifying important clinical issues are important clinical teaching functions (4).
 Given the press of expanding work loads, time for teaching and learning can be reduced. Attending physicians need to build into work and teaching rounds time to reflect upon the activities of the day. Without this protected time, the lessons to be learned from the cases being seen are lost.
 Students need practice opportunities for skill and concept development. By matching the problems of patients to the levels of skills students have attained, Faculty members pace students toward competence. In learning skills, students need to know what they are to learn. During the early periods of practice, they require brief guidance and help in discovering the critical cues that will allow them to evaluate their performance. The learning process is not complete without feedback the knowledge of results.
 The second component of clinical supervision is promoting problem-solving and critical appraisal skills. Learning theorists like Jerome Bruner (14) argue that teachers motivate students best when they tap their natural ability to attempt to solve problems and make decisions. Students will have greater interest in learning if instructors create an atmosphere in which students are challenged to inquire and discover for themselves the answer to important content questions. Attending physicians and residents need to engage students actively in the process identifying patient problems and developing management plans. Student should be asked to verbalize their underlying thinking processes and to defend their recommendations. Attending physicians and residents should also their own thought processes so that students can understand the processes used in reaching decisions.
 The third major requirement of an effective clinical supervisor is to observe objectively student performance and offer constructive feedback. In the training of athletes, a great deal of time is spent defining performance criteria, challenging athletes
to exceed current skill levels, and providing them with extensive feedback on performance. This typically involves extensive use of videotapes and computer monitoring of performance over time. As with athletes, without detailed feedback medical students have no external information upon which to base improvement strategies or to determine how they are progressing toward their goals. Faculty members and residents need to provide students with factual, descriptive, and, where possible, positive comments upon their performance. Feedback tends to be the most effective when students know the criteria that will be used, feedback is provided at the earliest opportunity, and students are able to compare self-assessment with expert judgment. Systematic and targeted feedback is one of the most powerful teaching tools available and yet the least utilized.
 Students need professional support and encouragement to deal with the stresses of the clinical environment and with their own performance anxieties. The professional and emotional support of concerned faculty members or residents can alleviate much of this stress and anxiety. Several studies on counselor supervision indicate that trainees who received empathy, warmth, and acceptance from their supervisors became significantly more open to their own experiences (15) and succeeded better at instilling these characteristics in themselves (16,17). This supportive affective stance of the supervisor provides the necessary conditions for personal change: freedom from fear, empathy, warmth, and genuineness.
 Effective clinical supervisors provide structure to the learning environment, promote problem-solving and critical appraisal skills, objectively observe and offer feedback on student performance, and provide professional support and encouragement.

The first two teaching roles (role-modeling and clinical supervision) involve direct interaction with medical students.
 Instructional leadership and scholarship activities occur outside of the context of direct clinical teaching. Three components of instructional leadership are curriculum development, the evaluation and improvement of teaching, and educational research.
 Efforts in curriculum development should promote excellence in clinical education. Attention needs to be given to the organization of clerkships, specification of learning objectives, identification of reasonably concise educational resources, and clearly defined evaluation procedures. Students and faculty members need to understand the criteria and procedures to be used in evaluating student performance.
 Changes could be made in basic clerkships to reduce students' responsibility for routine work and increase emphasis upon problem-solving, psychosocial and ethical issues, and health promotion. Advanced clerkships could then be used to prepare students for intensive residency-level training. Strategies for enhancing self-directed learning by students should also be encouraged as part of the basic clerkship design.
 Evaluation and improvement of teaching are important aspects of instructional leadership. Evaluation of teaching in clinical settings has not been implemented as systematically as evaluation of teaching in classroom settings. Consequently, critical decisions affecting the professional lives of medical school faculty members (for example, self-improvement of teaching, academic promotions, and merit pay increases) are often made without benefit of accurate information on clinical teaching effectiveness. To enhance high-quality academic decision-making, there is need for reliable, valid, and useful evaluation instruments for clinical instruction. A system that integrates quantitative measures of teaching (student and resident ratings of classroom and clinical teaching), descriptive documentation (faculty teaching), and qualitative judgments (peer review) on the full spectrum of instruction in medicine has been developed at the University of Washington School of Medicine (18).
 Systematic evaluation of clinical teaching is necessary because of the limited number of students who observe an attending physician or resident on a given rotation. Thus, clerkship coordinators need to ask that all students evaluate the major attending physicians and residents who have taught them. Over a six-month to one-year period, adequate numbers of ratings are accumulated for most faculty members and residents upon which to make reasonable assessments of their teaching abilities. These data should be shared with both faculty members and residents in a context that promotes reflection and improvement. One model used at the University of Washington School of Medicine is semiannual faculty development workshops for specific departments. These workshops have been successful in helping both faculty members and residents to improve their teaching abilities and to strengthen the clerkships.
 Part of the academic enterprise is the creation of new knowledge. This task can be applied to teaching and learning in clinical settings as well. Faculty members can investigate issues concerning clinical instruction on their own or in collaboration with faculty members who have backgrounds in education. The collaborative research model, in which a faculty member from a clinical department works with a specialist in education, has produced excellent research in medical education. Further research is needed in numerous areas: clinical reasoning and problem-solving processes, team learning in clinical settings, new educational models for experiential learning, unstructured learning versus highly structured learning in clinical contexts, the application of information technology to clinical instruction, and the relationship between teaching excellence and learning outcomes.
 While instructional leadership functions are less visible to students than direct clinical teaching, these functions do exert a powerful influence on the design and implementation of clinical clerkships. A well planned educational program combined with a motivated, high quality faculty can create a dynamic learning environment for students.

Medical schools, like other organizations, are in a constant state of change. The change process involves the adaptation of the school to its environment in ways that are consistent with its value system. The diffusion of new ideas and their acceptance within a school are enhanced by the utility of the idea, its compatibility with the organizational culture, and the prestige of those promoting the idea (19). Creating significant changes in clinical teaching will require the development of creative and useful ideas that are promoted by medical school leadership and that are consistent with faculty values. Some of the available improvement strategies can be described under the headings of leadership, institutional policies and procedures, and faculty development.
 Leaders set the tone and help shape the value system of the medical schools' hospitals and clinics. If the dean, associate deans, and departmental chairmen are strongly supportive of the teaching mission of the school, the faculty will perceive its importance and respond accordingly. Medical school leaders can demonstrate their commitment to teaching by allocating the necessary resources needed to offer outstanding clinical instruction. Every opportunity should be taken to highlight the importance of teaching for the faculty, for example, highlighting academic issues first in faculty meetings, articulating the values and virtues of teaching at faculty gatherings, and setting a positive role model of concern for the well-being of medical students.
 Institutional policies and procedures implement the values and the mission of the school at an operational level. Teaching excellence should be rewarded through academic promotions, merit pay, and teaching awards. To do this requires systematic evaluation of teaching so that documentation can be available at critical junctures in the decision-making process.
 Residents, like members of the faculty, should be rewarded for their teaching. In major teaching hospitals, residents should be selected on the basis of their commitment to teaching evaluated for their  teaching performance, and promoted in part on the basis of their teaching effectiveness. Residents require time in their work load for this teaching function and should be trained to perform this vital task.
 Faculty development activities are designed to help faculty members and residents improve their teaching skills and to modify their instructional practices so that students develop better attitudes toward learning and learn more from the instruction. There are several generic strategies for achieving such improvements (20-22).
 Workshops and seminars--The most frequently used technique involves short-term, intensive workshops and seminars designed to change participant attitudes, generate enthusiasm for teaching, and/or develop specific instructional skills. These workshops focus on the instructional process rather than the content to be taught. Examples of workshop topics include clinical supervision skills, demonstrating clinical procedures, feedback skills, problem-based instructional strategies, and lecture skills. Workshops often include practice with feedback, as in micro teaching. Evidence from a variety of academic settings suggests that workshops and seminars can positively affect teacher behavior, student ratings, and student learning (20,23).
 Consultation--Personal consultation involves the use of a specialist in the teaching process to help faculty members improve their teaching. Consultants work with faculty members to diagnose teaching needs, design new approaches to instruction, develop new skills, and evaluate the effectiveness of instruction. Technical assistance is provided to meet the faculty member's perceived need. This is a powerful and well documented method of changing teacher behavior (20,24,25).
 Collaborative research--Educational research conducted jointly between an educational researcher and a physician is an improvement method advocated by some medical educators, An applied educational research study becomes the mechanism for resolving educational problems through the development and testing of new techniques of teaching and learning in medicine, Faculty members who participate in such research gain new insights into the educational process and frequently become concerned about broader educational issues as well.
 Extended learning approaches--These programs take the form of long term learning experiences such as one-year sabbaticals, fellowships, and formal degree work in education. Participants regularly report that such programs have a significant personal impact upon them.
 Grants to support faculty projects--Grant competitions are held in some schools for faculty members who propose teaching-improvement projects. Grants may be used to purchase material, pay personnel, support travel, provide release time, and permit consultation with educational specialists. In the process of completing the projects, faculty members can gain new skills, design new instructional resources, develop greater enthusiasm for teaching, and create a communication network with like-minded faculty members in their own institution and in others. Grant programs are an inexpensive mechanism for promoting educational innovations (20,21).
 Assessment of teaching--Feedback from student ratings and peer review of teaching can serve as an impetus for changed teaching, particularly if specific suggestions for improvement are included in the comments. Self-assessment can also be useful if based upon specific criteria. In a review of the literature, Levinson-Rose and Menges (20) concluded that feedback to faculties from student ratings does lead to teaching improvement, especially when supplemented with consultation. Student ratings of clinical teaching, when combined with semiannual departmental workshops in faculty development, resulted in improved student ratings.
 Faculty development programs, in their varied forms, can have a positive impact upon the knowledge, skills, and attitudes of faculty; the attitudes and learning of students; and student ratings of instruction (20,21).

Clinical teaching is a challenging task for attending physicians and residents. They are called upon to serve a variety of roles in the context of clinical practice. There is much to celebrate about the provision of clinical education as well as much to change. The strategies identified can be used to enhance the quality of clinical instruction. The challenge for each individual, department, or school is to identify the three to five tasks that they can effectively achieve to promote a renewed commitment to excellence in clinical teaching.

  In an overwhelming number of cases instructors neglect to observe trainee doing a history or physical exam. It is possible for trainee to complete his training without ever receiving feedback or assessment based on direct observation of his performance in a patient interaction setting . The result is that students develop inefficient or frankly wrong practice habits based on their perceptions of how interviewing and examination should be carried out. Often  simlple corrective suggestions would  greatly improve the acquisition of skills by the trainee. Many examining bodies have perceived clinical skills deficiencies in trainees and more and more are insisting on direct performance observation of candidates as a basis for assessment.

  The clinical instructor can play a vital role in correcting these deficiencies by devoting time to the direct observation of students or residents. One useful practice during ward rounds involves asking one team member to conduct an interview with a patient he does not know and to instruct the other group members to observe his techniques with a view to giving a critical analysis. A similar critique can be carried out as he performs a physical examination. The group discussion and feedback following can be immensely valuable both to the person observed and the members.

  In any circumstances where an instructor or an examiner directly observe a trainee he can assess the whole spectrum of abilities including his social interaction skills, his ability to perceive and follow clues, his ability to modiify strategies if the need arises and ability to perform an ordered, complete and competent physical examination. Such sessions as affording excellent assessment opportunities provide the clinician with an ideal circumstance for powerful feedback.

นพ.วราวุธ  คัดสำเนามาจาก  : Clinical Teaching Strategies for Physicians
โดย P.J. McLeod & R.,M Harden,   Centre for Medical Education, The University Dundee,  17 กรกฏาคม 2537