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Teaching and learning opportunities in the clinic setting

‘Show me a medical student who only triples my work and I will kiss his feet’
Law 11, The House of God, Samuel Shem (1978)

Both undergraduate and postgraduate teaching and training are common in the GP surgery and outpatient clinic settings. However, service demands often make this a poor learning and teaching experience.

Spencer sets out the models commonly used in these areas (se diagram below). Most of us will remember the ‘observer’-type model from our own undergraduate studies, where one is expected to absorb important clinical facts and areas of the consultation by a mystical osmotic force. This model is commonly used in busy clinics and surgeries and, in a similar manner to the business ward round, provides a poor learning experience. Augmenting this model by setting some learning objectives for the observer will help to structure the learning: ask learners to critique the interactions (when too busy to run through a difficult consultation) or to note down areas they would like to discuss afterwards. Set time aside after the clinic to address any areas that arise.

Seating arrangements

My own experience running a training clinic for several years taught me that both with the undergraduates and postgraduates, the hot seat model is by far the best, if time and patients (and patience!) allow. However, I would suggest a slight variation on the triangular set-up of the seating suggested by Spencer (2003). As shown below, I would suggest that once the initial introductions have been made the teacher/trainer should sit slightly behind the patient and carers. This allows the consultation to flow far more naturally between patient and student/trainee and stops the patient being able to refer to the teacher if and when the trainee gets into difficulties. Likewise the teacher and student can keep eye contact, allowing the teacher to send non-verbal cues to the student and interrupt prior to any difficulties arising. The hot seat model should be used with a certain degree of caution for more junior undergraduates who may struggle with such a challenging role.

Hot seat diagram

Whichever model one chooses, the patient (and carers) should be informed of the student and teacher’s role and given the right to refuse to participate in the teaching session, without prejudice to their care. In my experience, sending out a letter of explanation with the outpatient details is usually enough to encourage most patients to participate.

See 'Teaching and learning in the community', 'Teaching and learning in outpatients settings' and 'Using the clinical consultation as a learning opportunity' on the Explore around this topic page for more ideas about ward-based, GP-based and clinic-based teaching.


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