Integrating teaching into the busy resident schedule: A learner-centered approach to raise efficiency (L-CARE) in clinical teaching

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Practice points

Learners who do not seem to have time for learning are challenging for teachers, who should consider the trainee's personal and professional context for an appropriate educational diagnosis. Efficient teaching is possible when offering effective (high-quality) and learner-centered teaching while avoiding “overteaching”. The L-CARE in Clinical Teaching model integrates educational diagnosis principles, self-directed learning theory, and efficient teaching strategies to help maximize learning while minimizing time and energy requirements.

Table 1.  Educational diagnosis and management of challenging learners

Educational diagnosis and management of challenging learners
Learner
Environment (1)	Study (3)		Patient care (2)
Diagnosis Personal Health-related issues Familial Conjugal problems, demanding family life Social Eventful social schedule, multiple extra-medical engagements Management Learners with major and/or persistent problems should be referred to their program directors	Diagnosis Decreased motivation Management Be aware of learning context, clarify goals, create teachable moments (Wagner & Ash 1998), create the need to know (Rubenstein & Talbot 2003), use tools such as Five clinical teaching microskills (Neher et al. 1992) and SNAPPS (Wolpaw et al. 2003), discuss professional orientation (Boulé et al. 1995)	Attitudes	Diagnosis Professionalism issues (lack of respect for patients, falsification of documents, substance abuse, breach of confidentiality, etc.) Management Discuss with learner; sanctions depending on severity
	Diagnosis Lack of time management, organizational, and search strategy skills; low level of self-direction Management Provide support and encourage learning	Skills	Diagnosis Lack of clinical/procedural/communication/time management skills Management Provide support and encourage learning; use Bordage*) and RIME** as a feedback tool
	Diagnosis Lack of knowledge of available resources Management Provide support and encourage learning, match trainee's learning styles (Mohanna et al. 2004)	Knowledge	Diagnosis Lack of fundamental or clinical knowledge Management Provide support and encourage learning

*Bordage suggested a model to stage the learners’ knowledge and clinical reasoning skills through the curriculum: at early stages of training, learners have a legitimately reduced knowledge (stage I) and subsequently some show varying degrees of dispersed knowledge (stage II – poorly organized and superficial knowledge). Later in training, they ideally achieve an elaborated knowledge (stage III) where an encyclopedic grasp of detail supports clinical management. By the end of residency or more commonly after several years in practice, the learner should have reached the level of compiled knowledge (stage IV) implying expert rapid pattern recognition and more efficient practice. (Batty 2006; University of British Columbia Department of Family Practice 2008).

^**The RIME model illustrates progression of the learner from being reporter, interpreter, manager, and educator (Pangaro 1999).

Figure 1. Grow's stages of self-directed learning. Notes: The teacher's role is to guide learners through the improvement of their self-direction skills, learned through different stages: at first, the learner is dependent, then becomes interested, involved and finally self-directed. Teachers should take care to matching their teaching style to the learners’ stage of self-directedness, and progressively decrease their responsibility towards learning (move from being expert to motivator, facilitator and ultimately consultant). Illustrative diagram inspired from Grow (Grow 1991).

Table 2.  Efficient teaching strategies

Efficient clinical teaching strategies (4)
Be effective	Do not overteach
Develop qualities of effective teachers:
Attitudes
– Enthusiasm (Irby et al.1991)
– Modeling professional characteristics (Irby et al. 1991)
Skills	Skills
– Good interpersonal skills (Kilminster et al. 2007)	– Organization and clarity (Irby et al.1991)
– Clinical competence (Irby et al. 1991;Kilminster et al. 2007) Knowledge (Irby et al.1991)	– Good teaching (Kilminster et al. 2007) & group instructional skills (Irby et al.1991) – Clinical supervision skills (Irby et al.1991; Kilminster et al. 2007)
Assessment of environment/patient care and study (feelings)
– Diagnose the learner's situation	– Motivate the learner (Kilminster et al. 2007)
– Foster autonomy (Kilminster et al. 2007)
Establish learning needs (expectations)
– Structure supervision (regular timetabled meetings, early determination of learning objectives and supervision meetings content) (Kilminster et al. 2007)	– Ensure goals are achievable for the available time
– Agree on daily goals (Dobbie et al. 2005)
Identify resources and strategies (ideas)
– Adjust teaching style to the trainee's learning style and level of self-directed learning readiness (Mohanna et al. 2004) – Limit the number of patients the student sees (Dobbie et al. 2005) – Encourage “just in time” learning (Dobbie et al. 2005) – Choose among a variety of subjects for supervision (clinical management, teaching, research, administration, pastoral care, interpersonal skills, personal development, reflection) (Kilminster et al. 2007) – Manage time (Kilminster et al. 2007)	– Focus on one theme for the supervision half-day (problem-oriented learning) (Heidenreich et al. 2000) – Limit presentation time by using the Five clinical teaching microskills (Neher et al. 1992) or the pattern recognition technique (Heidenreich et al. 2000) – Limit teaching points by choosing one or two key concepts per teaching interaction (Heidenreich et al. 2000) – Link learning to caring: teaching should be directly relevant to the learner's patient problem (Reilly 2007)– capture the teachable moment when it occurs – Use learning pearls as a teaching tool (Crow, Jr 2004)
Promote self-assessment and provide feedback (impact)
– Provide constructive feedback (Kilminster et al. 2007), debrief and plan for the next session (Dobbie et al. 2005)	– Focus on issues that can be remedied

Figure 2. Learner-Centered Approach to Raise Efficiency (L-CARE) in Clinical Teaching. The L-CARE in clinical teaching model illustrates the encounter of a learner and teacher in their personal and professional context, when they both have personal, familial and social environment (1) needs and concerns. Above and beyond, the professional environment is largely devoted to patient care (2) and study time (3) (or continuing professional development/faculty development and administrative duties). Teaching (4) has to find its place in this mutually dense schedule. In this model, the learner is illustrated with the left circle and the teacher is represented on the right. The concentric shapes represent the required attitudes, skills and knowledge for both members. The learner and teacher circles are overlapped to create the teaching environment. The central cycle illustrates the learner-centered approach in self-directed learning. CPD/FD: continuing professional development/faculty development.

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