How to improve clinical teaching

1. How to Improve
Clinical Teaching
Hirotaka Onishi MD, MHPE
International Research Center for Medical Education
University of Tokyo

2. Topics
1. Overall structure
2. Clinical skills
 physical examination skills
 procedural skills
 communication skills
3. Precepting

3. 1. OVERALL STRUCTURE

4. Japanese Situation
 Many students complain that they don’t
do practical work
 Many teachers complain that they have
to accept many students to teach
 University hospital executives complain
that students can’t do medical practice
 Need to change system

5. Keys for
Quality Clinical Education
 Medical students’ active participation
in patient care (learning by doing)
 Appropriate case mix (patients)
 Support and instructions from senior
physicians, nurses, etc
 Learning resource availability
5

6. How Did You Learn Clinical
Medicine?
 Do as seniors are doing
 Modify the way you do by feedback
from seniors, nurses or peers
 Normally old attendings do not offer
many teaching in clinical settings
 And not necessary!

7. Why Is Clinical Teaching
Difficult?
 First patient, next teaching
 Patient-centered care and student-
centered education concurrently
 Most attending cannot wait!

8. Different Methods/Settings of
Clinical Teaching/Learning
 Methods
 Demonstration and observation
 Shadowing (imitating)
 Practicing with responsibility
 Settings
 Classroom
 Practical room
 Real setting (ward, OPD, ER, etc)

9. Methods
Settings
Classroom
Practical
room
Real setting
(ward, OPD,
ER, etc)

10. Balance of
Learning and Service
Medical Students Residents Attendings
10
Clinical Teaching Function

11. How Much Retained
Active > Passive Learning
Average
retention rate
National Training Laboratories, Bethel, Maine, USA
5%
10%
20%
30%
50%
75%
80%
Lecture
Reading
Audiovisual
Demonstration
Group discussion
Practice by doing
Teach others
Active
Passive

12. Adult Learning Theory
 As becoming adult, people more learn
based on
 their experiences and perceptions,
 social roles,
 self directed needs, and
 self developed plans/objectives.
 Clinical teachers should stimulate above
 Do not spoon feed!

13. Why Adult Learning?
 Feed him a fish, he survives a day. Teach
him how to fish, he survives for long.
— Old proverb in China
 Students should discover and solve
problems, then apply it for another
opportunity.
 Students would like to contribute to
patients.

14. Who Learns from Whom?
 U of Geneva, Switzerland
Med
Student
Chief
Resident
Attending
Resident
15% 14%33%
23%
34%37%
15% 29%
Acad Med 1998;73(Suppl.10):S54-S56

15. Work Round
 Students and interns
present cases to residents.
 Residents give feedback
to students and interns.
 They see all the patients
of the team and learn how
to perform interview and
physical examination
Attending Round
 Resident select cases through
the work round for teaching
purpose.
 Preceptors and teaching staff
discuss cases and give
feedback to
residents/interns/students.
Students:
1 Gather patient data for presentation and documentation
2 Learn medicine for better decision making
3 Assist interns in executing patient management plans
Interns:
1. Manage patient care with orders
2. Plan patient care decision to be checked by residents
3. Gather patient data for presentation and documentation
Residents:
1. Make most of clinical decisions
2. Manage the team including interns and students
3. Teach interns/students in work round
2. Teach and Supervise young clinicians
3. Take responsibility of patient care
Preceptors
Teaching staff
Attending physicians:
1. Coordinate own dept with
other depts
Design of Clinical
Teaching Team

16. 2. CLINICAL SKILLS

17. Clinical Skills
 Physical examination skills
 Procedural skills
 Communication skills  another dept

18. Importance of
History and Physical
Hampton et al (1975) British Medical Journal 2:486
66
7
7
Relative contribution of
history and physical to diagnoses (n=80)
Diagnosis made on
history alone
Diagnosis changed after
physical examination
Diagnosis changed after
investigation

19. Physical Examination (PE)
 Procedures to obtain information from
patients after history taking
 Different procedures
 Inspection
 Auscultation
 Percussion
 Palpation

20. Traditional Model for
PE Education
 See one, do one, teach one
 This does not mean “one time” will be
enough to see before doing
 This means “learners should observe how
others do before doing” and “learners
should teach others after acquiring skills”

21. Three Levels
 Basic Level: Acquiring appropriate skills
 Learners have to learn specific procedures for each
body system (cardiology, GI, ENT, neurology, etc).
 Intermediate Level: Able to identify abnormality
 Learners have to recognize normal variance and
different findings from it.
 Advanced Level: Able to use abnormal findings for
differential diagnoses
 Learners have to understand the reason why
abnormal findings happen.
 Diagnostic hypotheses are listed and abnormal
findings are checked accordingly.

22. How to Find Abnormality
 Inspection, Auscultation: Pattern recognition
 Many experiences of normal/abnormal findings are
required to know the difference
 Differential diagnoses may give a clue to find
 Percussion, Palpation: Accurate procedures
and cognitive skills to identify abnormality
 Read the patient’s response
 More difficult to confirm abnormality by others

23. Points to Skills Education (1)
 Feedback is extremely important
 Basic level: Appropriate skills
 Self-monitoring, practice with friends
 Intermediate or advanced level: Ability to
find abnormality
 Cross-check with experienced physicians,
another test results/images

24. Basic level
 Self-monitoring
 Learners have to reflect their own
procedures and cross-check with textbook
 Practice with friends
 Learners get feedback from a friend
 Learners can experience patient role

25. Intermediate or advanced level
 Cross-check with experienced doctors
 When a learner felt some abnormality,
he/she asks a physician to confirm.
 Cross-check with an objective test
 Ex) When a learner think pleural effusion
exists, he/she confirmed it with x-ray film.

26. Points to Skills Education (2)
 Standardization of items/skills
 If different physicians use different items or
skills, young learners may confuse
 For some items, physicians separately use
different items for both purposes of
screening and confirmation
 Ascites:
 Shifting dullness – Screening
 Wave motion – Confirmation

27. How to Standardize Skills
 Discussion among experts
 Expert physician’s demonstration
 Movie

28. Procedural Skills
 Simulation is more needed before
actual practice
 Step by step practice following detailed
description or instruction (techniques or
tips) is recommended

29. Venipuncture – Preparation
1. Safety Needles, 22g or less
2. Butterfly needles. 21g or less
3. Syringes
4. Blood Collection Tubes. The vacuum tubes are designed to
draw a predetermined volume of blood. Tubes with different
additives are used for collecting blood specimens for specific
types of tests. The color of the rubber stopper is used to
identify these additives.
5. Tourniquets. Latex-free tourniquets are available
6. Antiseptic. Individually packaged 70% isopropyl alcohol
wipes.
7. 2x2 Gauze or cotton balls.
8. Sharps Disposal Container. An OSHA acceptable, puncture
proof container marked "Biohazardous".
9. Bandages or tape

30. Venipuncture – Procedure
1. Identify the patient. Outpatients are called into the phlebotomy
area and asked their name and date of birth. This information
must match the requisition. Inpatients are identified by their
arm band. If it has been removed, a nurse must install a new
one before the patient can be drawn.
2. Reassure the patient that the minimum amount of blood
required for testing will be drawn.
3. Assemble the necessary equipment appropriate to the patient's
physical characteristics.
4. Wash hands and put on gloves.
5. Position the patient with the arm extended to form a straight-
line form shoulder to wrist.
6. Do not attempt a venipuncture more than twice. Notify your
supervisor or patient's physician if unsuccessful.

31. 7. Select the appropriate vein for venipuncture. The larger median cubital,
basilic and cephalic veins are most frequently used, but other may be
necessary and will become more prominent if the patient closes his fist
tightly.
 Factors to consider in site selection:
 Extensive scarring or healed burn areas should be avoided
 Specimens should not be obtained from the arm on the same side as a
mastectomy.
 Avoid areas of hematoma.
 If an IV is in place, samples may be obtained below but NEVER above the IV
site.
 Do not obtain specimens from an arm having a cannula, fistula, or vascular
graft.
 Allow 10-15 minutes after a transfusion is completed before obtaining a blood
sample.
8. Apply the tourniquet 3-4 inches above the collection site.
Never leave the tourniquet on for over 1 minute. If a tourniquet is used for
preliminary vein selection, release it and reapply after two minutes.

32. 8. Clean the puncture site by making a smooth circular pass over the site
with the 70% alcohol pad, moving in an outward spiral from the zone of
penetration. Allow the skin to dry before proceeding. Do not touch the
puncture site after cleaning.
9. Perform the venipuncture
a. Attach the appropriate needle to the hub by removing the plastic cap over
the small end of the needle and inserting into the hub, twisting it tight.
b. Remove plastic cap over needle and hold bevel up.
c. Pull the skin tight with your thumb or index finger just below the puncture
site.
d. Holding the needle in line with the vein, use a quick, small thrust to
penetrate the skin and enter the vein in one smooth motion.
e. Holding the hub securely, insert the first vacutainer tube following proper
order of draw into the large end of the hub penetrating the stopper. Blood
should flow into the evacuated tube.
f. After blood starts to flow, release the tourniquet and ask the patient to open
his or her hand.
g. When blood flow stops, remove the tube by holding the hub securely and
pulling the tube off the needle. If multiple tubes are needed, the proper
order of draw to avoid cross contamination and erroneous results is as
follows:

33. 1. Blood culture vials or bottles, sterile tubes
2. Coagulation tube (light blue top)
3. Serum tube with or without clot activator or silica gel (Red or Gold)
4. Heparin tube (Green top)
5. EDTA (Lavender top)
6. Glycolytic inhibitor (Gray top)
h. Each coagulation tube (light blue top) should be gently inverted 4 times after
being removed from the hub. Red and gold tops should be inverted 5
times. All other tubes containing an additive should be gently inverted 8-10
times. DO NOT SHAKE OR MIX VIGOROUSLY.
i. Place a gauze pad over the puncture site and remove the needle.
Immediately apply slight pressure. Ask the patient to apply pressure for at
least 2 minutes. When bleeding stops, apply a fresh bandage, gauze or
tape.
j. Properly dispose of hub with needle attached into a sharps container. Label
all tubes with patient labels, initials, date and time.

34. Venipuncture
 Video

35. 3. PRECEPTING

36. Reflective Practice for
Clinical Reasoning
 Students/residents notice real setting key
point by reflection in action, and they
realize unwritten rule by reflection on
action independently or in the group.
 They have to share what they did not
know while they listen to or examine the
patient to improve their clinical reasoning.

37. Reflection-in-Action
 While medical interview
 Differential diagnosis of LLQ pain?
 How should I ask this to the patient?
 This notification of “weakness” will help
them diagnose the next patient

38. Reflection-on-Action
 While preparation for the presentation
 I should have asked this info…
 Why didn’t I notice the differential
diagnosis at that time…
 If they know how to overcome the
weakness, they can improve clinical
reasoning for the future

39. Experiential Learning Cycle
Theory
Reflection
Students will see an abd pain outpatient
 P : Ask category of differential Dx for abdominal pain.
 E : A student interviewed the patient.
 R : Case presentation. Ask tentative Dx and its reason.
 T : Some deeper discussion
Experience
Planning

40. Role of Case Presentation
for the Preceptors
 To confirm if the diagnosis and
management is OK
 To diagnose clinical reasoning ability
of the students/residents
 Quality of case presentation depends on
the quality of the information gathered
 Quality of information depends on the
quality of differential diagnoses and
problem representation

41. 1-minute Preceptor
 Determine the level of the learner
 Listen
 Get a commitment
 Probe for supporting evidence
 Teach general rules
 Tell them what they did right
 Correct mistakes
 Learner-initiated objectives

42. One-minute preceptor
 Simplest model for teaching
1. What do you think?
2. Why do you think that?
3. What I’m thinking
4. Where do we go from here?

43. Skit 1
St: 70 yo woman has got high fever of 39.0
degree. She has also productive cough since
last night.
Dr: Does she have pneumonia? Did you order
any blood test?
St: WBC 12000 with 15% of stab. CRP is 12.8.
Dr: OK. Definitely pneumonia. Please give her
Unasyn (ABPC + SBT).
St: How much?
Dr: 1.5g, two times a day.
St: OK, sir.

44. Skit 2
St: 70 yo woman has got high fever of 39.0
degree. She has also productive cough since
last night.
Dr: What do you think?
St: I think pneumonia is most probable.
Dr: Why do you think that?
St: I heard coarse crackle on her right lower area.
Gram stein of sputum showed diplococcus.
WBC 12000 with 15% of stab. CRP is 12.8.

45. Dr: OK. I agree with your diagnosis. What do you think
the next step is?
St: I’d like to give her Unasyn (ABPC + SBT).
Dr: Why do you like to use Unasyn?
St: Well…I don’t know why many doctors use Unasyn
for this condition.
Dr: Because pneumococcus has high probability of
resistance to ABPC nowadays.
St: All right. I will administer it.

46. Clinical Teaching 
Asking Relevant Questions
 Asking relevant questions to each
condition is the most important skill for
clinical teachers.
 If a student does not understand
important issues, do not blame on it
otherwise students will hide their ideas
to teachers.