Strategies for Teaching in a Busy Practice

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Basics of Observation

What are the principle advantages of observation in your teaching? How can observation assist in your teaching?

What are the principle disadvantages of observation as part of your teaching. What are your main concerns about doing more observation of learners?

The principle advantages listed by practitioners and in the literature are:

direct assessment of key skills
impression of overall performance
insights to use of clinical reasoning and problem solving
directly pertinent to clinical practice
enhances learner-teacher partnership

The principle disadvantages reported are:

time
insecurity about "how to do it"
unpredictability - teacher is not completely in control
limited in assessing knowledge: focuses on the actions rather than the rationales
tends to be subjective
the "Hawthorne" effect (the presence of the observer changes the usual behavior)

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You are already a skilled observer. Working with patients requires that you are an expert at gathering, processing, and prioritizing large volumes of verbal, tactile, and non-verbal information. On every patient encounter you are "Sherlock Holmes" making complex but reliable judgements -- remember Sherlock Holmes was written by a physician and the character was modeled on Joseph Bell, a professor of surgery!

Using your observational skills in teaching has many similarities to patient care.

As a teacher you...

Prepare the situation
Initially, this can feel awkward, but it pays huge dividends in successful teaching and patient satisfaction when done well. The learner, patients, teacher, and office staff need to know what is going on and appreciate its importance. Unless someone explains the arrangement, the patient is likely to be uncertain as to why the learner is present, or why their usual physician is apparently being passive. A brief explanation of what is expected is also essential for the learner to benefit from the encounter and may assist the teacher stay in role. (A major problem with observation is that physicians find staying silent very difficult!)
Watch and listen for specific items or actions
Interpret, clarify and instruct based on the observation

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Quote

As a teacher you decide...

The purpose of the observation	What do you need to know about the learner? Early in the rotation, you may be focused on general style, communication abilities, or skills in physical examination in order to help you assess the learner and plan his/her experience in your practice. Towards the end of the rotation, you may need more information in order to complete evaluation documents that require a detailed knowledge of learner performance. Throughout the rotation, observation helps the teacher monitor progress or address specific needs. Some teachers select one patient per session where the learner conducts most of the patient encounter under direct supervision.

The format of the encounter	The three most common styles are: Active watching: Teacher is a "fly on the wall" with no intervention during the patient encounter, but discussion and teaching take place immediately afterwards. Participatory observation: Teacher gets involved if requested by learner or at a predetermined stage of the process. Examples include when a learner performs a part of the physical examination, then the teacher advises on technique and/or demonstrates the examination to confirm the findings; or the teacher intervenes when the learner requires additional information, clarification or redirection. Demonstration: The teacher is observed by the learner

The follow-up	Observations set up powerful teaching situations. The learner is ready for immediate feedback on performance or is ready to ask questions about a patient encounter they have just observed.

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Observation need not take a lot of time and saves time by providing good first hand information about learners.

The purpose and format of the observation should be clear to all.

Patients and office staff can also act as observers and provide feedback to learners.

Without observation,
the artillery commander does not know where the target is,
or if his efforts have had any impact!

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Community-Based Teaching Benefits - Strategies for Teaching in a Busy Practice
The Precepting Microskills - Observation and Feedback - Bedside Teaching
What is Evidence-Based Medicine? - Teaching Evidence-Based Medicine
The Ten-Minute Talk - Strategies Home Page