Comments on: On learning climate

By: mo

mo — Mon, 28 Jan 2008 07:07:21 +0000

Because I get a chance to orient and work with med students in the ICU as a RN I can tell you right off how to teach. First start out by saying hello. Yes, I know it sounds silly but you should be shocked at how often no one bothers to say hello and introduce themselves to med students.
Be proactive and start rounds by explaining the patients problems and issues and then stop and ask your med students if they are okay and do they understand. If someone asks a question get EXCITED, A question is a teaching moment. You are the teacher by the way. Ask the med student where you lost them, See, this gives the student the opportunity to demonstrate they aren’t morons, still just a student. Link up where they got lost to where they need to be.
I work in a huge academic center in Toronto, our Attendings don’t teach, they pontificate and it makes me crazy. I can present my patient in five minutes or less. I can state the issues and my opinions on how to solve these issues. Most Attendings completely lose the plot and start nattering on about obscure, useless studies no one cares about.
Attendings need to shut up and listen. Rounds are not the Attendings chance to show off, it’s the med students time to learn and practice that learning.
And keep your sarcastic or belittling comments to yourself. I can become irate if an attending starts in on a resident or a med student…I won’t allow it at my bedside.
I love having a med student. It’s great to be around someone who really wants to learn. Why the Attendings who get paid to teach are so hateful? I don’t know..I teach for free and love it.
I think the best thing for a teacher is to be compassionate and professional.

By: Bad Medicine » One Two Three Four . . .

Bad Medicine » One Two Three Four . . . — Wed, 23 Jan 2008 02:46:51 +0000

[...] at medrants, DB asks how we can improve the learning climate in teaching hospitals. I suspect this crap is not what he [...]

By: Jared

Jared — Sun, 20 Jan 2008 18:30:17 +0000

Oh, one other thing. Knee-jerkish, I know. But, always, always, always, be skeptical of the current mod-ish teaching practices. E.g. quality-based, evidence-based, etc. Certainly use them as a starting point; however, they are simply models that are meant as a lowest common denominator and should be expressed as being minimally dressed.

By: bev M.D.

bev M.D. — Sun, 20 Jan 2008 18:12:55 +0000

Ah, better when it actually appears! OK, I trained 30 years ago so hopefully things have changed, but what I remember most clearly is on any internal medicine-type rotation when everyone stood outside the door and quoted references to each other to prove how smart they were (this was mostly the residents and attendings). I found this incredibly boring and unhelpful as a medical student. With the new emphasis on evidence-based medicine, it is good as an attending to let the students know that actually VERY LITTLE of what we do has good evidence behind it, but they should still seek it out if possible. Also, an open, friendly climate is critical, particularly with the influx of more female medical students, who are less likely to speak up and/or try to BS the attendings/residents. Sorry to the guys, but that’s the way I experienced it….till I got tough enough to give it right back. But is that the way we really want it to be?

By: bev M.D.

bev M.D. — Sun, 20 Jan 2008 18:08:09 +0000

I am testing my comment first because right now it’s coming out in unreadable tiny print…..

By: phil

phil — Sun, 20 Jan 2008 03:17:43 +0000

I agree with the comments about not wanting to ask an attending any questions. Some of them will crush you for uttering “I don’t understand”. I also had one attending tell me I was “trying to get too involved”. Another attending once responded to me not understanding her point by repeating what she said louder and slower. On the other hand, you learn a bit better when there’s a little bit of pressure. Just try to apply pressure without being a jerk.

And, as always, keep it simple. There is a limit to how much information you can cram into your head at a given time, but wide swaths of things can be understood when a good teacher is present.

By: Alexa Blue

Alexa Blue — Fri, 18 Jan 2008 03:22:48 +0000

Hard to answer this question without the acrid taste of sour grapes. Similar to Alex, I think pimping (and I should note I’ve never really had much “bad pimping”) is an effective way of teaching, but my guess is that it’s a terrible way of evaluating (fun experiment would be to get attendings who regularly teach students to guess their board/MCAT scores and rank their fund of knowledge along some ordinal scheme, and see how well those estimates match up to the actual objective measures).

I suspect this is a rather banal point, but I value things about myself that aren’t typically measured or talked about in medical school (eg I read fiction not by Michael Crichton). In general months, tend to be looser, friendlier, more productive, and result in better grades for me when the attending makes some gesture at reaching out to the non-medical side of me (unclear if the better grades represent better performance by a more comfortable me, softer grading from friendly or sympathetic attending, or what). Anyways, my general experience has been that this is pretty infrequent.

By: famdoc

famdoc — Fri, 18 Jan 2008 03:11:44 +0000

One of the interesting things that I have noticed is how family medicine is taught and how different it is in the world outside of academic institutions. People are still trying to make you a doctor as you percieve a 100 yrs ago who is always there with his “black bag”… we all see that it is clearly not working since the American health care system is so not designed to work for/with primary care. The residencies are not trying to teach better ways to tackle the system or make the system work for you, rather they are teaching that we need to do exactly what medicare and managed care companies want us to do, only better…
I feel this is the same generation that has brought family medicine to where it is today and let is slip out of mainstream.
The teaching culture needs to change… ACGME needs to rethink the role of family medicine in 2008. When are we going to realize that we cannot bring back the 1800s…
Instead of teaching us to be good surgeons, good hospitalists, good psychiatrists, good pediatricians and good everything… we should make good Primary care docs and prove to this country that there cannot be “universal” health care or any other good care if the real care providers are not happy campers…

By: dmad

dmad — Fri, 18 Jan 2008 02:59:41 +0000

I agree with the “don’t ask the attending” as they will ask you to research it or do a presentation on it… “go look it up”. I think the information gained on the field (at bedside) always sticks better and helps the resident who is watching the attending treat people and trying to put everything together at bedside. If the questions are answered right there and then, the info is just more likely to stick… On the wards, there is usually not enough time to “go look it up”…

By: Jared

Jared — Thu, 17 Jan 2008 20:48:33 +0000

The learning climate for whom? You should probably start by encouraging your group to consider who they are instructing. Is the pedagogical method going to be appropriate, or should something more androgological (adult-learning) be used?

The best learning environments, first and foremost, teach to the level of the students. One should strive not to leave students in the dust, but one should also not move so slowly as to insult their intelligence.

Next, is engagement. I generally do some sort of non-sequitur at the beginning of lessons I teach (ACLS, generally, but also intravenous fluids courses for the military) I will give something to kick-start their brains. If I go into something that the majority of the class isn’t interested in as the book I’m teaching from does, they’ll never become engaged. If I engage them first, then they’ll engage the material through me.

Finally, provide some simplification. For example, one of my gross anatomy instructors would take something that is initially very difficult to get to stick, like the arterial supply of the gut, and give us the gloss of it in a completely different method than the textbook, make sure we understood the gloss, and move from there. In this example, if we didn’t understand the celiac trunk, SMA, and IMA, we really shouldn’t move on to the tributaries of any particular one. And, then he also kept on the subject of also studying from the aspect of anastomoses as those are areas the body knows need a dual blood supply–so the question then becomes “why?”.

But, above all, respect the intelligence of the learners. They are not dumb, they just don’t know yet.