Developing a training program to improve supervisor-resident relationships, step 1: defining the types of issues.

BACKGROUND: By some estimates, the teacher-learner relationship explains roughly half of the variance attributed to the effectiveness of teaching. Despite this, relationships largely have been ignored in the educational literature. PURPOSE: This qualitative pilot study sought to identify factors in the supervisor-resident relationship that hinder learning among University of Toronto psychiatry residents. METHOD: Thirteen postgraduate-year residents in Years 2-5 and their supervisors were interviewed regarding interactions that either assisted or adversely affected learning. RESULTS: Qualitative analysis of the interview data led to the identification of 5 types of issues affecting the supervisory relationship: goals and individual differences, communication and feedback, power and rivalry, support and collegiality, and role modeling and expertise. Face validity was supported when typed anonymous written feedback obtained from annual supervisor evaluations also could be organized into the 5 categories. CONCLUSIONS: Recognition of the types of interpersonal interactions that assist or hinder learning may contribute to enhanced teaching effectiveness.

Conversations with parents of medically ill children: a study of interactions between medical students and parents and pediatric residents and parents in the clinical setting.

BACKGROUND: The traditional remedies applied by medical schools to the perennial problem of teaching "caring competence" have been unsuccessful. PURPOSE: Our purpose was to design and evaluate a simple and effective method for helping students maintain affective contact with their patients. METHODS: Third-year medical students and pediatric residents were given the opportunity to talk informally with parents of medically ill children and reflect on the value of this experience for their learning. Trainees' opinions of the experience were measured with focus groups and a questionnaire. RESULTS: Trainees were delighted with the experience, particularly with the following aspects: the opportunity to hear a personally relevant story told in a sincere manner, the realization that they could have an authentic interaction "even" in a medical setting, and the usefulness of the information they derived from the conversation. CONCLUSIONS: We concluded that something unique to the conversational experience has educational value.

The life long challenge of expertise.

The development and maintenance of expertise in any domain requires extensive, sustained practice of the necessary skills. However, the quantity of time spent is not the only factor in achieving expertise; the quality of this time is at least as important. The development and maintenance of expertise requires extensive time dedicated specifically to the improvement of skills, an activity termed deliberate practise. Unfortunately, determining how to engage in this deliberate practise is not obvious for tasks such as diagnosis, which involve high stakes and are predominantly cognitive nature. Reflection on and adaptation of one's cognitive processes is important; this could be supplanted by seeking out the opportunity to engage in trial and error in low risk environments such as simulators. Regardless, most individuals tend to favour well-entrenched activities and avoid practise. This may be due to lack of awareness of deficiencies in performance. However, it may also be due to the individual's conception of the nature of expertise. Although expertise requires experience, experience alone is insufficient. Rather, the development of expertise is critically dependent on the individual making the most of that experience. As a result, motivational factors are fundamental to the development of expertise. Overcoming deficiencies in self-monitoring is not a sufficient remedy. It is also necessary is that clinicians form an attitude toward work that includes continual re-investment in improvement.

Meeting the challenge of a changing teaching environment: harmonize with the system or transform the teacher's perspective.

The beliefs that teachers hold about the appropriate roles and responsibilities of teachers shape the ways they teach and the ways they think about teaching. In this paper I describe four teaching roles based on a taxonomy that I've recently developed. Teachers who are guided primarily by the Content Expert Role view themselves as experts who serve as resources, like books or pictures. Teachers who are guided primarily by the Performance Role view themselves as agents who make learning happen by transmitting information or shaping students. Teachers guided primarily by the Interactive Role view themselves as guides who facilitate learning by interacting with learners. And teachers guided primarily by the Relational Role view themselves as engaged in relationships with learners for the purpose of helping them. Using examples taken from the health sciences I explain how each of the four teaching roles might succeed or fail depending upon the position that it occupies within a teaching-learning system. When teaching is viewed as part of a system, not as something a teacher does to a learner, teachers are successful if their particular contribution to the system is essential to the learning system. I also describe the process whereby teachers expand their belief system to include more roles. Such changes in belief systems are major shifts that qualify as "perspective transformations". Perspective transformations take place slowly and are typically attended by strong emotions. I end this paper with advice to teachers regarding ways they can harmonize with the educational system or face the challenge of perspective transformation.

Curriculum renewal in child psychiatry.

OBJECTIVE: To ensure uniform design and evaluation of a clerkship curriculum for child and adolescent psychiatry teaching common disorders and problems in an efficient manner across 5 teaching sites and to include structures for continuous improvement. METHOD: The curriculum committee selected for course inclusion disorders and problems of child psychiatry that were commonly encountered by primary care physicians. Instruction methods that encouraged active student learning were selected. Course coordination across sites was encouraged by several methods: involving faculty, adopting a centralized examination format, and aligning teaching methods with examination format. Quantitative and qualitative methods were used to measure students' perceptions of the course's value. These evaluative results were reviewed, and course modifications were implemented and reevaluated. RESULTS: The average adjusted student return rate for course evaluation questionnaires for the 3-year study period was 63%. Clerks' ratings of course learning value demonstrated that the course improved significantly and continually across all sites, according to a Scheffé post-hoc analysis. Analysis of student statements from focus-group transcripts contributed to course modifications, such as the Brief Focused Interview (BFI). CONCLUSIONS: Our curriculum in child psychiatry, which focused on common problems and used active learning methods, was viewed as a valuable learning experience by clinical clerks. Curriculum coordination across multiple teaching sites was accomplished by including faculty in the process and by using specific teaching and examination strategies. Structures for continuous course improvement were effective.

OSCE checklists do not capture increasing levels of expertise.

PURPOSE: To evaluate the effectiveness of binary content checklists in measuring increasing levels of clinical competence. METHOD: Fourteen clinical clerks, 14 family practice residents, and 14 family physicians participated in two 15-minute standardized patient interviews. An examiner rated each participant's performance using a binary content checklist and a global process rating. The participants provided a diagnosis two minutes into and at the end of the interview. RESULTS: On global scales, the experienced clinicians scored significantly better than did the residents and clerks, but on checklists, the experienced clinicians scored significantly worse than did the residents and clerks. Diagnostic accuracy increased for all groups between the two-minute and 15-minute marks without significant differences between the groups. CONCLUSION: These findings are consistent with the hypothesis that binary checklists may not be valid measures of increasing clinical competence.

Improving Feedback for Medical Students in a Family Medicine Clerkship: Evaluating medical student performance using frequent feedback.

To evaluate whether feedback to medical students could be improved by asking teachers to complete a student performance rating form during a family practice clerkship, the authors had students and teachers fill out a questionnaire. Teachers in the intervention group reported observing students more frequently. Students' perceptions of feedback frequency correlated strongly with their ratings of feedback quality.

Teaching physicians about teaching: an experiential workshop.

Teaching improvement workshops are most effective when they engage teachers actively in practice teaching, particularly when the teaching situation is similar to the actual one to which the teachers will return. Teachers, however, often find such involvement threatening. In this paper we describe a 3 h workshop which succeeds in overcoming teachers' reluctance to participate in situations that are relevant to their real teaching problems, students, and subject matter. The most exciting outcome, in our view, was teachers' increased sensitivity to the limitations of their teaching approach and their increased awareness of the role of their concept of teaching in shaping their teaching strategies. Weaknesses of the workshop include its dependence on the skills of a group director, the tendency of the group to seek a single right answer instead of exploring alternatives and the usual danger of role rigidity which troubles all role enactment procedures.

Medical students' early expectations and later opinions of aspects of their first year.

A survey of medical students on their first day of medical school and again near the end of their first year measured the discrepancy between their expectations of various aspects of the first year and their retrospective opinions about these aspects. The entering students had specific, detailed expectations about numerous aspects, many of which were not confirmed by their subsequent experience. The same students were reminded, one year later, of their unfulfilled expectations about the first year and were asked to describe any effects these expectations had had on class emotional climate and morale. They recalled both serious disappointments and pleasant surprises but no general change of class morale. A serendipitous finding was the profound indifference of the second-year students to their first-year emotional responses. Our results challenge the general practice of basing curriculum renewal programs on cross-sectional student surveys with no consideration of baseline expectations, and of relying on students to initiate improvements in educational programs.

Observation as a method of learning: a useful learning experience or a waste of time?

In medical schools, most clinical teaching takes place in small groups in which the teacher and/or one of the students carry out the interview, examination or procedure, while one or more of the other members of the group looks on. Students, then, are as often watchers as doers. What do students learn from observing someone else doing something, and what can be done to enhance the effectiveness of this learning process? The authors attempted to answer these questions. They conducted an experimental study designed to evaluate student experience as observers. The data garnered from this study indicated that students regarded learning by observation as a useful, even valuable, experience. The data also suggested that the effectiveness of this learning experience was derived from a shared sense of immediate, emotionally charged, highly interactive participation in the proceedings, and that the teacher's catalytic function was essential to this process.

Changes in undergraduate attitudes toward medical ethics.

To detect any change in medical students' attitudes toward medical ethics, students from the same class were given a questionnaire on their first day of medical school and again near the end of their fourth year of study. The results showed a strong shift away from the students' initial expectations that they would rely on specialists or scholarly sources in the future; the need for a medical ethics course in the curriculum, while still felt, was less important to them by the fourth year. The reasons for these changes were not apparent, for the students' levels of knowledge and perceptions of the role of ethics in medicine in the first and fourth years did not differ. It is recommended that medical school faculty actively reinforce the initially positive attitudes of students during clinical supervision.

Interpreting educational concepts for the teaching family physician: some parallels between patient care and undergraduate clinical education.

Three of the most widely used concepts in education, objectives, curriculum, and evaluation, have direct parallels in primary care. This parallelism suggests an approach which may help family physicians both in understanding these educational concepts and in applying them with judgment. By drawing specific attention to the parallels and by the use of examples drawn both from clinical practice and from teaching, the author hopes to encourage physicians to view their teaching as an analog of clinical skills that are already familiar to them. This approach is applied to the problem of accommodating to individual differences in students, the most difficult obstacle to the proper application of educational concepts.