Teaching on the run

Volume 181 - Issue 3

Teaching on the run tips 4: teaching with patients

Authors:  Fiona R Lake and Gerard Ryan

Med J Aust 2004; 181 (3): 158-159. || doi: 10.5694/j.1326-5377.2004.tb06208.x
Published online: 2 August 2004
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Setting

You usually see your patients and then teach outside their room. You do this because you worry that the junior medical officer or student might come up with something that will upset the patient. But recent reports suggest your concern may be unfounded.

There should be no teaching without the patient for a text, and the best teaching is often that taught by the patient himself.1

This advice by William Osler, at the beginning of the 20th century, has been continually handed down since then. Osler’s style wouldn’t be acceptable today, with large rounds, and consent rarely obtained from the patient. Now, simulation is being used for teaching, but teaching that involves patients remains invaluable. Teaching with the patient rather than about the patient should be considered vital for students, junior medical officers and registrars to learn the practice of medicine.

Benefits of teaching with the patient

Patients like to be included in the teaching process. Case presentations by junior staff at the bedside significantly increase the time doctors spend with patients, and such patients are more likely to be satisfied with their inpatient stay.2 They prefer having students present their history in front of them than outside the door.3

Teaching with patients allows the important domains of learning to be integrated through teaching, observation and role modelling.4,5 These domains include:

  • Clinical (knowledge, decisions, skills)

  • Professionalism (ethics, teamwork)

  • Communication (with patients, families and other staff).5

Teaching with the patient incorporates adult learning principles, as it is meaningful, relevant to work, and allows active involvement (see “Tips 2”6).

Downsides of teaching with the patient

Patients may be adversely affected by teaching in their presence if their rights are not respected,4,7 or if the teacher fails to recognise that patients may have conditions not appropriate to be discussed in front of a group.7

The patient’s perception as to the competence of the junior medical officer or registrar may be harmed by negative feedback that senior clinicians give in front of the patient. Remember that the doctors in training are the ones the patient sees on a daily basis.

In some instances, the patient may be upset and confused by the discussion.2,7

Patients want to be asked for consent beforehand and to be introduced to people. They appreciate an approachable tutor, clear explanations, the opportunity to ask questions, and the feeling that their feedback is valuable.2,4

How to teach with patients in the clinical setting

Plan your teaching using the “Set, Dialogue and Closure” framework (see “Tips 3”8). Important factors in teaching with patients include choosing the correct patient, obtaining consent, and explaining the patient’s role.

Structure your dialogue using methods described such as the “One-minute teacher” and SNAPPS (see below). These have been shown to significantly increase learners’ motivation, their involvement in decision-making, evaluation of their knowledge, and provision of feedback.9,10

Aids to teaching with patients
The “one-minute teacher”

The “one-minute teacher”9 uses five steps to direct the learner’s focus to a key aspect of a case, and the clinician teaches around that issue. Feedback is explicitly given (a step we often omit when busy). The clinician

  • Asks the learner to outline his or her diagnosis or management plan;

  • Questions the learner for reasoning;

  • Teaches general rules (take-home points);

  • Provides feedback on what was done well; and

  • Corrects errors and suggests what could be improved.

SNAPPS

In the “SNAPPS” approach,10 the learner

  • Summarises the case;

  • Narrows the differential diagnosis;

  • Analyses the differential diagnosis;

  • Probes (asks the teacher about areas not understood);

  • Plans management; and

  • Selects an issue for self-directed learning.

SNAPPS makes learners do most of the work, through justifying their thinking and exploring what they don’t know (rather than questioning them on what they do know!). A pilot study of SNAPPS showed that learners were more actively involved and readily came up with questions, whereas in more traditional interactions they rarely did. The teachers were relieved of having to think up questions and, instead, could respond to the learner.10

Before you try out the “one-minute teacher” or SNAPPS, orient your learners so they know what to do and expect.

Take-home message

When teaching with patients, remember that:

  • Patients like being involved in teaching sessions (as long as their rights and wishes are respected).

  • Teaching with patients incorporates adult learning principles, in that it is meaningful, relevant to work, and allows active involvement.

  • Good communication with patients is important: ask for their consent, ensure understanding, and ask for questions and feedback.

  • Teaching methods like the “one-minute teacher” or SNAPPS can make teaching and learning more efficient.

Authors

  • Fiona R Lake MD, FRACP1
  • Gerard Ryan MB BS, FRACP2
  • 1. Education Centre, Faculty of Medicine and Dentistry, University of Western Australia, Nedlands, WA.
  • 2. Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Nedlands, WA.

Competing interests

None identified.

Acknowledgements

We would like to thank the teachers and participants in Teaching on the Run courses for their input, and the Medical Training Review Panel, Australian Department of Health and Ageing, for funding support.

References

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