Strenghts
and Challenges in Clinical Teaching
.........................................................................................................................
Dr. Firdous Jahan
Clinical teaching and learning should be focused
on directly involving patients and their problems.
Clinical examination fulfils several other important
roles. Examination is an integral part of the
doctor-patient relationship. The simple 'human
effect' of listening to and touching a patient
can be intrinsically reassuring and comforting.
Within this relationship, trust is essential,
not only to be able to perform parts of the
examination itself but also in subsequent decision
making and management. It is very hard to convince
a patient that they must undergo various, occasionally
invasive and possibly painful, investigations
if they have little trust in the clinician.1
The examination may provide important information
about the diagnosis, prognosis and severity
of the patient's condition. This also enables
decisions to be made regarding appropriate investigations
and therapy. Thorough, systematic examination
may narrow or confirm a diagnosis where the
patient gives little or no history, or presents
with vague or non-specific symptoms. Thus clinical
examination confirms diagnostic suspicion from
the history, and directs the investigations
and further management of the patient.2 Traditionally,
clinical teaching occurred in hospital wards,
outpatient settings and operating theatres.
During the past 20 years, clinical skills centers,
laboratories and more recently, simulation centers
with high-fidelity simulation have been introduced
into clinical settings. Clinical skills teaching
have never been the ideal teaching and learning
environments, and they are becoming increasingly
more difficult to use as service demands stretch
goodwill and reduce opportunity. However, workplace-based
learning is vital for the acquisition of a comprehensive
range of clinical skills that can be used in
a variety of complex situations.3
Clinical teachers optimize the teaching and
learning opportunities by modification of a
person's behavior through his/her activities,
experiences, his/her knowledge, skills and attitude
including modes of adjustment towards the environment
change.4 Adult learning occurs when individuals
engage in sustained, systematic learning in
order to effect changes in their attitude, knowledge,
skills or belief systems.
"Tell me, and I will forget, Show me, I
may remember, Value me, and I will understand.
I discover and I use (quotation by a Chinese
philosopher Confucius 450BC).
A good teacher ideally completes an alignment
of the level of behavior, competencies, beliefs
and professional identity.5 Medical education
continuously evolves reflecting the latest developments
in modern medicine and prepares students as
future facilitators. Professional development
in clinical teaching and learning may be cognitive
means knowledge based or experiential which
utilizes previous experience, and is participative
learner centered, problem-based, relevant to
work and based on learner's needs. It is a continuous
process in which new experiences build on and
integrate with the accumulated experiences.6
Significant learning takes place when subject
matter is relevant to the personal interest
of the student. New attitudes are more easily
assimilated when threat to the self is low;
it is self initiated self directed, with planning,
setting a positive climate for learning balancing
intellectual and emotional components of learning.
Learning in the clinical environment has many
strengths. It is focused on real problems in
the context of professional practice. Learners
are motivated by its relevance and through active
participation. Skills of history taking, physical
examination, clinical reasoning, decision making,
empathy, and professionalism can be taught and
learnt as an integrated whole.7 Clinical teaching
has many challenges too. It is mostly opportunistic
lacking clear objectives and expectations, focuses
on factual recall rather than on development
of problem solving skills and attitudes. Sometimes
it may be done by passive observation rather
than active participation of learners. Inadequate
supervision and provision of feedback makes
is more difficult. In clinical set up there
is little opportunity for reflection and discussion.8
Clinical teachers have time pressures competing
demands, administrative and research activities
to balance with negligible rewards and recognition
for teaching. These challenges to the clinical
tutor, maintain the balance between education
and clinical service provision. A wide range
of out patient facilities and specialties make
it more challenging. The difficulties associated
with our patient teaching are usually related
to organizational issues and physical environment
as well as tutor and students ratio. Clinical
teaching in all aspects nurtures a student to
develop knowledge, skills and desired attitude
for better patient care.
For effective clinical education we can use
e-learning modules in clinical settings. This
is how some manage the process within the framework
of clinical service delivery. It allows both
students and teachers to make wider connections
with other aspects of the curriculum, promotes
greater standardization of teaching, complements
traditional methods of clinical skills learning
in a blended fashion and promotes inter professional
education and sharing of reusable learning objects.
The current approach to the learning outcomes
tends to be either entirely assessment focused,
or focused on the linear transmission of information.
Technologies which are associated with collaborative
learning seem to fit within their own category
of e-learning. An obvious advantage of e-learning
is that it has the potential to interact with
the learner and can be easily updated without
needing to wait for the next publication. Delivery
of a blended course, with access to e-learning,
may provide one solution for a more effective
learning experience.9
Although teaching in outpatients is opportunistic,
with care full planning and identification of
appropriate learning goals one can avail unique
opportunities to address a wide range of health
care issues.10
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409-14.
- Ramani S. Twelve tips to promote excellence
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- John Spencer. ABC of Learning and teaching
in medicine: Learning and teaching in the
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- Mayell, S J, Shaw, N J. Assessing senior
house officers' perceptions of learning. Arch.
Dis. Child 2008; 93: 1022-1026.
- Firdous J, Shazia S, Saira K, Abdullah
K, Hasan H. Attributes of effective clinical
teacher: A survey on Students' and Teachers'
perception. JCPSP July 2008; 18(6): 357-361.
- Molodysky E, Sekelja N, Lee C. Identifying
and training effective clinical teachers--new
directions in clinical teacher training. Aust
Fam Physician. 2006 Jan-Feb; 35 (1-2): 53-5.
- Bowen JL, Irby DM. Assessing quality and
cost of education in the ambulatory setting:
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2002; 77: 621-680.
- Pratt, D., Arseneau, R., & Collins,
J. (2001). Reconsidering "good teaching"
across the continuum of medical education.
Journal of Continuing Education in the Health
Professions 2001; 21(2): 70-81.
- Knutson D, Cain T, Hurtubise L, Kreger
C. Lessons learned: Developing e-learning
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- Sheikh SH. A Reform agenda outline for Medical
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