Would Socrates Have Actually Used the "Socratic Method" for Clinical Teaching?

Medical students and residents are familiar with clinical teaching methods in which a faculty member poses a series of questions to them. This technique is often called the "Socratic method," but it is frequently perceived by learners as an attempt to demean them, a practice that is colloquially known as "pimping." The distinction between Socratic teaching and pimping lies in the perception of "psychological safety." Psychological safety allows learners to answer questions or ask for help without threats to their dignity or worthiness. In a psychologically safe clinical teaching context, learners recognize that questions posed by attending physicians probe their current understanding and guide them to expand their knowledge. In pimping, questions are posed to embarrass the learner and to reinforce the teacher's position of power over them. Absent a threat of disparagement or condemnation, learners are able to focus on building schema for knowledge, skills, and attitudes, rather than worrying about shielding their self-worth. This article presents the proper Socratic method, as intended by Socrates, and contrasts it with pimping. This perspective defines psychological safety as the pivotal factor distinguishing Socratic teaching from pimping, and establishes the foundation for empirical studies of these common practices in medical education.

Evidence-based and population-based medicine: national implementation under the UME-21 project.

BACKGROUND AND OBJECTIVES: The Undergraduate Medical Education for the 21st Century (UME-21) project developed and implemented innovations to medical school curricula at medical schools across the country. This report describes the development and implementation of innovative approaches to improving instruction in evidence-based medicine with a population-based perspective. METHODS: Each school participating in the UME-21 project designed, implemented, and evaluated its own unique curriculum initiatives. We examined these initiatives using data abstracted from written reports submitted to the project Executive Committee. Additional data were obtained by personal communication with project directors and evaluators at the various schools, student and preceptor comments, internal program evaluation at each school, and external evaluation by the UME-21 project leadership. The Association of American Medical Colleges Graduation Questionnaire was also used. RESULTS: Fourteen of 18 participating schools implemented a broad range of curricula to facilitate teaching and learning about evidence-based and population-based medicine. Common themes included the application of evidence to patient care, use of clinical practice guidelines and pathways, and the general incorporation of evidence-based techniques (literature searching, critical appraisal, etc) into the teaching of other content, such as clinical science and managed care. Teaching approaches included Web-based and other computer-based education, an emphasis on active and self-directed learning, use of small groups and workshops, and distribution of this content over multiple years. As an alternative to full-length evidence-based medicine courses, many schools incorporated an evidence-based approach into existing courses and clerkships. Data demonstrated an upward trend in student satisfaction with how topics were presented at UME-21 schools. CONCLUSIONS: These innovations successfully demonstrated that evidence-based and population-based medicine content can be introduced into medical school curricula. Introducing these constructs in ways that demonstrate their relevance to patient care facilitates student learning.

Teaching the basics of clinical pharmaceutical care: innovative pharmacy workshops at the University of Wisconsin and the University of Nebraska.

BACKGROUND: Safe and effective prescription writing, using drug formularies, and managing pharmaceutical care are skills medical students need to acquire. Spurred by the Undergraduate Medical Education for the 21st Century (UME-21) grants, the University of Wisconsin and the University of Nebraska independently developed educational workshops to address these competencies. METHODS: The University of Wisconsin's workshop is presented to medical students at the start of their third year. They receive information from pharmacists on medication errors, prescription writing, and drug formularies. A "learners guide" summary is discussed by a physician, which brings into focus the clinical application of the didactic session. A small-group session follows with hands-on experience in writing prescriptions and using formularies for three patient case scenarios. The workshop at the University of Nebraska consists of three sessions during the third-year internal medicine clerkship. In the first session, pharmacists discuss formularies, the Pharmacy and Therapeutics (PT) committee, and the preparation of a drug monograph. During the second session, students develop an evidence-based drug monograph on a product or herbal. In the final session, the class functions as a mock PT committee, and after listening to the drug monographs, determines whether the product should be added to the formulary. We evaluated students' satisfaction with the workshops using Likert scales and assessed students' ability to correctly fill out a prescription form. RESULTS: Both workshops were well received. The mean rating at University of Wisconsin was 1.7 on a scale of 1 (satisfied) to 7 (dissatisfied), and at University of Nebraska it was 3.8 with 5 (outstanding) to 1 (unacceptable). At the University of Wisconsin, on a year-end skills assessment involving 148 students, 100% of the students properly filled out a prescription. Ninety-four percent received an excellent grade, 6% a pass, and no marginal or failing grades were given out. CONCLUSIONS: The workshop on pharmaceutical prescribing was rated favorably by students. After participating in the workshop, students acquired skills in prescription writing.

From library to discharge: a managing care student project.

BACKGROUND AND OBJECTIVES: The Patient Care Project (PCP) was a central component of the Undergraduate Medical Education for the 21st Century (UME-21) grant project at the University of Nebraska. With the primary goal of improving students' critical thinking skills, the PCP was directed more toward an understanding of managing care than the business aspects of managed care and emphasized written communication skills, clinical hypothesis testing, and exploring ways to solve medical and ethical questions. METHODS: All 239 students graduating in 2000 and 2001 were required to analyze the medical care received by one of their hospitalized patients. Using a criterion-based evaluation tool, students' written critiques were assessed in five specific areas, all of which required critical thinking skills. Students also received an overall grade for the project. The UME-21 Graduation Survey was used to assess changes in attitudes and behavior. Students graduating in 1999, prior to the institution of the PCP graduation requirement, served as a control group. RESULTS: The most frequently discussed topic of the PCPs was cardiovascular disease. The mean overall rating by the faculty for the PCPs was 3.7 and 3.8 in academic years 2000 and 2001, respectively (maximum=5). In a qualitative analysis of the PCPs, students demonstrated insight into their patients' overall medical care, including the use of evidence-based medicine (EBM), quality improvement, and cost containment. There were no statistically significant differences, however, between the PCP and control groups on the UME-21 Graduation Survey. Nonetheless, more students who had completed the PCP reported that they had identified the total cost of a patient's stay, designed a quality improvement loop, and obtained clinical evidence from an EBM computer database. On this same survey, all students agreed with the use of clinical practice guidelines and cost containment. CONCLUSIONS: The PCP appeared to be relevant to the students' learning needs, and they provided cogent critiques of the medical care they had rendered as well as critical analyses of their patients' discharge summaries and the cost of care including ways to reduce cost. On the other hand, we were unable to demonstrate any substantial differences in the results of the UME-21 Graduation Survey given to both the PCP and control groups. In spite of this lack of effect on students' attitudes, the PCP was perceived by the faculty to be valuable and has been incorporated into the required third-year family medicine clerkship at the University of Nebraska.