Effective multilevel teaching techniques on attending rounds: A pilot survey and systematic review of the literature

Figures & data

Table

Practice points

Despite attendings’ concerns about the challenge of teaching to multiple levels of learners on rounds, trainees at all levels found most teaching on attending rounds to be useful. Teaching techniques that helped facilitate learning among multiple levels of trainees included: Broadening, Targeting, Novelty, Up the Ladder, and Student as Teacher (see Table 1 for descriptions). If questions are constructed carefully, it is possible to challenge advanced trainees while also teaching junior trainees.

Table 1.  Descriptions of multilevel teaching techniques

Technique	Description	Example^a
Broadening	Change the specifics of a given case to make it more challenging or interesting	“What if the patient were 45 instead of 75? How would that change management?”
Targeting	Target medical knowledge or management questions at specific team members based on the difficulty of the question	“Paolo, how do we decide if a patient with pneumonia needs to be admitted? … John, what are the most common bacteria that cause community acquired pneumonia? … Great. Susan, what are some of the possible complications of pneumonia that we should watch for in this patient?”
Novelty	Offer new data	Discuss a newly published article
Up the Ladder	Ask the same question to the medical student, then the intern, then the resident, etc.	“John, in this patient with a recent variceal bleed, what treatments should we consider? … Paolo, what do you think? … Susan, how do you think about it?”
Student as Teacher	Have a more senior learner train a more junior one	“Susan, can you show John how to evaluate for ascites?
Multi-Answer	Seek many answers to the same question	“Here we have a patient with shortness of breath and a fever. What do you think is the most likely diagnosis and why? … OK, we’ve heard that Paolo thinks the patient has a PE because of a recent hospital stay. What do the rest of you think?”
No Right Answer	Ask questions with no single correct answer	“When and how should we tell the patient his diagnosis?”
Teaching to the Top	Teach to the most senior trainee on the team	“Susan, the next thing to try in a heart failure patient who is already on maximum doses of inotropic agents and cannot tolerate further afterload reduction is …”
Extreme Challenge	Teach at a level above everyone on the team	“One way to study the development of drug resistance is to do a haplotype analysis …”

Note: ^aThe characters in the examples are a third-year medical student named John, an intern named Paolo, and a senior resident named Susan. The “speaker” is the attending.

Table 2.  Demographics of respondents

Attendings (N = 66)
Female (N, %)	20 (30)
Mean years of experience (mean, SD)	15 (12)
Self-identified title (N, %)
Hospitalist	23 (35)
Specialist	17 (26)
Primary care physician	22 (33)
Physician-scientist	4 (6)
Trainees (N = 89)
Female (N, %)	43 (48)
Median age (years)	28
Level of training (N, %)
MS3	17 (19)
MS4	5 (6)
PGY1	31 (35)
PGY2/3	20 (23)
PGY3/4	16 (18)

Figure 1. Perceived appropriateness of teaching. Mean estimated proportion of time that teaching on attending rounds was (a) above the trainee's level and not useful (Over My Head), (b) above the trainee's level but stimulated learning (Challenging), (c) appropriate to the trainee's level (Just Right), (d) below the trainee's level but a useful review (Review), or (e) below the trainee's level and boring/not useful (Boring). Error bars indicate 95% confidence intervals. Trainees are grouped by level into medical students (MS3/4), interns (PGY1), and residents (PGY2–4).

Figure 2. Estimated frequency of different techniques. Compares the percent of attendings who report having used a technique on their most recent teaching block to the percent of trainees who remember seeing the technique on their most recent rotation.

Figure 3. Trainees’ perception of techniques. Of those who observed the technique, percent of trainees describing the technique as very or somewhat effective.