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Models and approaches

It is important to plan and prepare for sessions that involve patients. Before the session, think about:

  • what preparatory work the learner needs to do (e.g. reading, skills laboratory, practice with peers)
  • where the teaching will take place
  • which parts of the teaching session require direct patient contact
  • whether you will be present or absent when the learner is with the patient
  • what role you will take (observer, instructor, demonstrator, questioner)
  • where discussions will take place and with whom (discussions don’t always have to be round the patient’s bedside, for example)
  • how you will build in opportunities for patient feedback
  • how you will build in debriefs for learner and patient
  • what follow-up learning or reading should be carried out.

 

‘The bedside is the perfect venue for unrehearsed and unexpected triangular interactions between teacher, learners and patient… teachers should be vigilant about grabbing teachable moments’ (Ramani, 2003, p. 114). We also need to be vigilant about identifying and seizing learnable moments, those times when a learner might do or encounter something when you are not present, but through professional conversation will reveal the learning. Just having ‘corridor conversations’ or having a coffee break with your learners can give time for these moments.

Below is a selection of models that might help you to think about and structure learning encounters involving patients and grab those ‘teachable moments’.

Janicik and Fletcher (2003, p. 128)

This model groups clinical teachers’ skills into three domains, identifying some of the key aspects that need to be attended to in each domain.

Domain I
Attend to patient's
comfort

  • Ask ahead of time
  • Introduce everyone to the patient
  • Brief overview from primary person caring for patient
  • Explanations to patient throughout, avoiding technical language
  • Base teaching on information about that patient
  • Genuine, encouraging closure
  • Return visit by a team member to clarify misunderstandings and thank patient

Domain II
Focused teaching

Microskills of teaching – modified for the bedside

  • ‘Diagnose’ the patient – what are the patient’s problems or treatment
  • ‘Diagnose’ the learner – what are their needs, what can you do for them today
    o    observe
    o    question
  • Targeted teaching
    o    role model
    o    practice
    o    teach general concepts
    o    give feedback

Domain III
Group dynamics

  • Limit time and goals for the session
  • Include everyone in teaching and feedback

 

Doshi and Brown (2005, pp. 224–6)

Shadowing (role
modelling)

Learner shadows a more senior practitioner and learns by observation
Tip – prior to the session identify active observation focus or questions that the learner will specifically look for

Patient-centred

Learner is allocated patients and follows their progress from start to end of episode of illness
Tip – useful to help learners actively learn patient management and problem solving; needs support through guided reading and discussion from teachers

Reporting back

Learner assesses the patients and reports back to the trainer
Tip – teacher needs to build in identified briefing and debriefing time with a structure and purpose to the feedback

Direct observation

The trainer observes the learner’s performance directly
Tip – follow rules of feedback, good for learning clinical skills; take care not to leave the patient as a passive participant in the process, think of how the patient might feed back to the learner

Videoconferencing interviews

The learner’s interview with a patient is recorded and later viewed with the trainer
Tip – needs consent from patient re images; good for learning consultation and communication skills; can be done with a group or single learner. Take care that the learner does not over-dwell on minor issues

Case conference

A case is presented by the learner and discussed by a wider audience
Tip – useful for multi-professional learning and inputs; teacher supports learner re the type of questions that might come up and how to present a case

Wave scheduling and hot clinics

This is a technique for including teaching time into a clinic or surgery in which the learner sees Patient 1 while the trainer sees Patient 2, then the trainer joins the learner to see Patient 1 and there is a gap in the appointments. This is repeated so that alternate patients (i.e. 1, 3, 5) are seen by both trainer and learner, and patients 2, 4, 6, etc., are seen by the trainer alone
Tip – this is a useful way of optimising busy ambulatory care clinics but needs careful scheduling, timekeeping and allocation of appropriate patients to the learner’s ‘list’

 

McKimm (2008)

A ‘Trialogue’ is a discussion between three groups with different principles, backgrounds and expectations: a structured three-way conversation (myDictionary.com). This model helps teachers maintain a balance between their obligations to the patient as well as those to the learner through dialogue and conversation.

  • The Trialogue focuses on relations and interactions. The relationship and interactions between practitioner (as teacher), learner and patient help to explain and structure complex teaching and learning activities in the clinical setting.
  • The Trialogue provides a model for analysing complex interactions between the three ‘players’ in clinical teaching settings through the metaphor of a continually shifting dialogue.
  • It provides clinical teachers with a framework for:
    • scaffolding learning
    • facilitating learner and patient active engagement in the learning process
    • ‘reflecting in action’ (Schön, 1991) to promote student learning whilst simultaneously attending to the needs of the patient
    • helping clinical teachers to pay conscious attention – ‘mindfulness’ – to the relationship and emerging dialogue between players.

 

 

TheTrialogue reflects concepts of the ‘parallel dialogue’ (Gergen et al., 1996) and the ‘inner consultation’ (Neighbour, 2004) suggesting that ‘expert’ clinical teachers (Proctor, 2001) operate within two sets of parallel processes: one attending to the patient (the inner clinical consultation) and one attending to the learner (the inner teaching dialogue). The role of the teacher is therefore two-fold, to help the learner develop a ‘therapeutic dialogue’ (connection, rapport) with the patient whilst maintaining their own therapeutic dialogue with the patient, and to develop and maintain a teaching dialogue with the student which facilitates learning. When true learning from the patient occurs, the teacher will also have facilitated a learning dialogue between the patient and the student.

See Teachers’ Toolkit for how to use the Trialogue to plan and review a teaching session involving a patient.

The module Facilitating Learning in the Workplace provides more ideas relating to specific learning interventions.

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