When the teacher is at the centre of the learning, didactic teaching approaches dominate and largely encourage surface learning. For effective learning, a learner needs to build on the blocks of their knowledge through practice, interaction, feedback and reflection.

Learner centred teaching requires turning the teacher as the “sage on the stage” on its head.

• The learner is at the centre – focus is on what the learner wants and needs to learn/practice.
• The medical teacher is a guide or facilitator to help them get there.

The following are all example of learner-centred strategies.

• Trainee presents case, followed by consultant probing questions and feedback
• Trainee leads the ward round /conducts examination– consultant gives explicit feedback
• Effective questioning – to probe, challenge and expand on what the learner knows – avoid the mini lecture
• Peer teaching
• Homework exercises to follow up on what they have seen eg: gaps

This example shows what a learner-centred ward round might look like using our ward round framework (STIC).

Set the roles/agenda.

“Today, if each team member takes the lead with one of our patients, then we can take a few minutes afterwards for feedback.”

Target and teach

The one minute preceptor approach could be used after reviewing chart, before trainee enters room, or after the encounter.

1. Before we go in the room, based on what you know what would be your plan for this patient today?
2. Is there anything else you would consider?
3. Why/why not? In general I think it is good practice to…
4. I agree…
5. I would also consider…

Inspect and reflect

Observation and feedback as set up in agenda.

Close

 “From what we did today, is there anything you would like to work on in future rounds?

Trainees are starting from different learning bases and have different learning needs. One size does not fit all in education. It can be difficult to know where to pitch teaching to each individual in a group setting.

Teaching to different levels requires:

• Understanding what your learners want /need to learn
• Knowing what level of knowledge they currently have
• Having an idea of complexity of knowledge /skill required at each level eg JRMO, Registrar, Medical student
• Giving trainees different tasks to do and providing feedback

Different strategies to multi-level teaching might work better in different circumstances. Some examples are:

• Teaching up the ladder
• The “merry go round” round
• Focus on one trainee/level
• Peer teaching
• Assign “homework” to address gaps between learners but remember to follow it up

Teaching “up the ladder”

• Start with open questions with the lowest level of learner
• Move up the ladder as knowledge is exhausted.
• Assign different tasks to learners depending on their level.
• Medical student – lists symptoms of a condition
• JRMO applies this to what they see in the patient
• Registrar evaluates treatment options

Take turns with different roles eg. The “lead” in the patient encounter, history-taking, examination, note-taking.
Rotate roles between patients so everyone gets a chance to be actively involved.

Focus could be on a different trainee (including students) each day or for different patients. “I want to focus on giving (the resident) a chance to examine today. I will examine also so we can see how we compare.”

Peer teaching and feedback

• When they appear confident in a topic area encourage senior trainees to teach junior colleagues with your support. Would you like to teach the others about this?   
• Assign trainees the task of giving each other feedback under your supervision. What did you think about XX’s examination and findings?

Methods to teach need to recognise that time is limited. Just as evidence informs clinical practice, evidence also supports teaching and learning methods which have been shown to be effective and efficient. OMP has been shown to improve teaching effectiveness and efficiency and increase teaching of higher order thinking.

A five step method which enables teachers to get learners to commit to a clinical decision, explore their reasoning and then generalise the learning.

One minute preceptor described in 5 steps.

1. Get a commitment
2. Probe for supporting evidence (explore the reasoning)
3. Reinforce what was done well (one point is enough)
4. Correct errors or misconceptions (one point is enough)
5. Teach a general rule

Some prefer to reorder the steps so you 3) reinforce 4) correct and 5) end by teaching a general rule, as it provides a summary to the discussion.

1. Get a commitment: What do you think is the most likely diagnosis?
2. Probe for supporting evidence: Why do you think they have an URTI? Did you consider anything else?
3. Teach general rules: In a child with chest-indrawing you must suspect lower respiratory involvement, even if you cannot hear abnormal sounds on auscultation.
4. Reinforce: I thought the diagnoses you considered were appropriate.
5. Correct: In this child who is sick and other respiratory signs a chest-X ray to confirm or exclude pneumonia is important

TIP: Questioning to get a commitment is the important step, it allows you to explore the reasons they have made this choice, and not another. Other examples include:

• What do you want to do now?
• What do you think is going on?
• How would you like to investigate this child?
• How do you want to manage (this issue)?
• If I weren’t here, what would you do?

Neher JO, Gordon KC, Meyer B, Stevens N. A five-step “microskills” model of clinical teaching. Journal of the American Board of Family Practice 1992; 5:419-24.

Active observation (the learner’s perspective) is also referred as activated demonstration (the facilitator’s perspective). It is a strategy to make the teacher’s expertise visible to the learner. It has been shown to prioritise learners’ needs – target then teach – and increase satisfaction with learning.

Active observation can be used to demonstrate a skill, an approach to history taking, communication, or a procedure. It is used when a problem is unfamiliar or challenging to the learner.

Active observation is described in different ways, here we outline 4 steps

1. Why? Provide a rationale for the observation
2. What should they watch? Declare what the learner should observe and then demonstrate
• “I want you to watch how I…”
3. What did they observe? Review what was observed
• Ask the learner what they observed
• Provide a rationale for the actions
4. What next? Allow or suggest an opportunity to practice, or a follow up task

1. Why?  It can be difficult to do a neck examination on a young child this age.
2. What should they watch?I want you to observe the strategies I use to examine for neck stiffness.
3. What did they observe?  What did you observe? How do you think that worked?
4. What next? Next time we have this situation, perhaps you can lead…

Other opportunities for activated demonstration may include:

• Physical examination
• Explanation of a diagnosis or management plan
• Breaking bad news
• Differentiating diagnoses on history
• Observing the method of history taking eg) the timeline of an illness

Effective questions draw out what the learner knows, extends their critical thinking and helps the learner make sense of new information. Questions that ask students to elaborate, justify and evaluate their ideas help with meta-cognitive reasoning.

• Open questions – open up the discussion, demonstrate learner knowledge, help work out where “to pitch” discussions.
• Probing questions - focus learning and allow the learner to justify or analyse initial responses.
• Hypothetical questions - encourages learners to think independently and more critically. Expands the repertoire of learning if similar common cases are being encountered often.
• Reframing questions - are used when learners don’t know the answer or content.
• Closed questions - are used to elicit specific information (often facts) - a short answer or yes / no response.
• Peer questioning – are used when learners exhaust their knowledge. “Phone a friend”.

The facilitator’s skill is deciding which questioning approach to use:

• Open questions are a good place to start, but often an open question is quickly followed by closed questions or “a spiel”. Try instead to follow with other types of questioning to draw out what learners know and expand on their answer.
• Use probing and hypothetical questions to expand or explore thinking.
• Reframe questions by giving some initial information or by breaking down the question into simpler concepts or principles.
• Use closed questioning to elicit specific information (recall).
• Use peer questioning to teach to different levels and facilitate collaboration between learners.

Pose, pause, pounce

• Pose a question, pause to give the group time to consider then direct it to someone if needed. Research shows you need to wait at least 3 to 5 seconds.

• Open: “What do you know about…?”
• Probing: “How would you..? Why choose that treatment? What about the patient’s presentation supports that diagnosis…?”
• Hypothetical: “Imagine…What if….When would you..?”
• Reframe: “So, if we take a step back and think about broad types of problems - what things might you be thinking about here?”
• Peer: “Can anyone help…? Would anyone do something different? What are others thinking?”

"Not so effective" questioning

Effective questioning

For learners to improve, they need to practice a new skill, be observed and receive explicit feedback. If they don’t get this feedback or just continue to be told “good” they are not getting an effective learning experience.

Constructive feedback is not just telling someone where they can improve, but how – not telling them that they are good, but why. The focus is on effective questioning to get the learner to see their gaps and then to help them construct a better way or approach.

Feedback on a round will not occur if it is onerous or if you aim too high. Start by aiming for a few minutes of feedback for each trainee after one patient encounter in which they lead.  Walk and talk to maximise time.

The One minute preceptor is one model for feedback. Here is another.

• Pre-warn the learner you would like to give feedback (Set agenda).
• Ask learners to self-critique – positives first, avoid negatives here.
• Discuss positives – give explicit examples.
• Seek permission to critique, point towards gaps and encourage self-reflection.
• Identify where and how they can improve.
• Get learner to identify strategies (close the loop of learning)

Pre-warn

• “I would like to observe you while you lead in this room and give feedback after. Is there anything you would like me to focus on?

Ask learners to self-critique

• “How do you think that went…? What did you think about the family’s understanding of your explanation?”

Positive Feedback - more than just saying “that was good! “Identify why it was good – be explicit.

• “Your explanation of asthma was succinct, clear and accurate. “
• “When you asked her to summarise what you had said, it was a great way of measuring her understanding.”

Point towards gaps

• “Did you feel like you addressed all of her/his concerns?”
• “You seemed unsure about/when…”

Identify where and how they can improve

• “How else could you have handled that? What else could you have said/done?”
• “Can I make some suggestions as to how I would do it? …what works for me?” Then give clear examples. “I think the content of your message was good, but you can help families understand by chunking information, sign-posting what you are saying and checking in with them as you go.

What to comment on? Choose one or two things

• Opening, building rapport and closing
• Structure
• Chunking and checking large chunks of information
• Verbal language
• Non-verbal cues
• Active listening
• Reading cues and responding with empathy statements

• Building rapport – introductions and time and space for the family’s agenda – Names – yours, your teams and parents and child all introduced.
• Structure – clear organisation of discussion and signposting. “First we will talk about what the blood tests show.” “Let’s focus on the management plan now.”
• Chunking and checking large chunks of information. “That’s a lot of information – can you summarise your understanding of our plan?” “So the next steps are 1…, 2…, and 3…”
• Verbal Language – clear, simple language at appropriate literacy level for family, avoid medical jargon, slow pace
• Non-verbal cues – sitting not standing, eye contact, body posture, no crossed arms, nodding, appropriate smiling!
• Active Listening – avoid interrupting. Clarify what you have heard – “Am I right in thinking that you are most worried about his breathing?”
• Reading emotional cues and responding with explicit empathy “I can see that not having an answer is really frustrating for you…”
• Reassurance – “He’s in the right place to sort this out…”
• Closing –confirm plan clearly and check understanding. “That was a lot of information, can you just tell me what you understand so I know we are on the same page?”

Giving feedback – Building rapport, Effective listening and Verbal communication

Giving feedback – Non-verbal communication and Empathy

Set an education agenda:

• Focus the education for the ward round including how it will be conducted, by whom and if/how feedback/education will be included.

Explicitly identify education as it occurs – Name it.

Summarise all implicit education – State education that has been covered

Set an education agenda

• “Is there something you would like to focus on today for your own learning?”
• “We have had a few cases of XX lately, since we are not busy I’d like to spend a few minutes discussing…”
• “If we have time, I want to come back to this topic at the end of the round…”
• “I would like to make sure we each get some feedback on the round today…”

Explicitly identify education as it occurs

• “I want to spend a few minutes on education around (topic)…”
• “Let’s do some education around interpreting Xrays…

Summarise implicit education

• “Let’s think about what we learned this morning…”
• “Did you learn anything new today?”
• “The key learning for me from today was…”
• “So we covered a few things today (list)…”