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Does good clinical teaching really make a difference?

      From personal experience, we know that our teaching can make a profound difference in the lives of our students. Yet, what is the empiric evidence for this strongly held belief? Investigators have sought to answer this question by identifying the behaviors of effective clinical teachers, developing evaluation tools to measure these behaviors, and evaluating the effects of these behaviors on the performance of students.
      Based upon the assumption that there is a general set of behaviors used by excellent clinical teachers, researchers have sought to identify these behaviors and then to design rating forms for students and residents to use to evaluate clinical teachers. In a series of studies, Irby (
      • Irby D.M.
      Clinical teacher effectiveness in medicine.
      ,
      • Irby D.M.
      • Rakestraw P.
      Evaluating clinical teaching in medicine.
      ,
      • Irby D.M.
      • Ramsey P.
      • Gillmore J.
      • Schaad D.
      Characteristics of effective clinical teachers of ambulatory care medicine.
      ,
      • Ramsbottom-Lucier M.T.
      • Gillmore G.M.
      • Irby D.M.
      • Ramsey P.G.
      Evaluation of clinical teaching by general internal medicine faculty in outpatient and inpatient settings.
      ,
      • Ramsey P.G.
      • Gillmore G.M.
      • Irby D.M.
      Evaluating clinical teaching in the medicine clerkship.
      ) identified six factors that were associated with clinical teaching excellence: knowledge and analytic ability, organization and clarity of presentation, enthusiasm and stimulation of interest, group interaction skills, clinical supervision skills, clinical competence, and professionalism. Building upon these studies and general principles of learning, Skeff, Stratos, and colleagues developed a faculty development program and an evaluation system to assess teacher behaviors. These clustered into seven areas: learning climate, control of session, communication of goals, understanding and retention, evaluation, feedback, and self-directed learning. Many investigators have used these behaviors to evaluate clinical teachers (
      • Litzelman D.
      • Stratos G.
      • Marriot D.
      • Skeff K.
      Factorial validation of a widely disseminated educational framework for evaluating clinical teachers.
      ,

      Marriott DJ, Litzelman DK. Students’ global assessments of clinical teachers: a reliable and valid measure of teaching effectiveness. Acad Med. 1998;73(suppl 10).

      ,
      • Skeff K.M.
      • Stratos G.A.
      • Berman J.
      • Bergen M.R.
      Improving clinical teaching evaluation of a national dissemination program.
      ). Using content analysis of residents’ written comments about clinical teachers in family medicine, Ullian et al (
      • Ullian J.
      • Bland C.
      • Simpson D.
      An alternative approach to defining the role of the clinical teacher.
      ) identified four aspects of effective clinical teachers as physician role model, supervisor, dynamic teacher, and supportive person.
      These studies share considerable congruence: excellent clinical teachers share a passion for teaching; are clear, organized, accessible, supportive, compassionate, and able to establish rapport; provide direction and feedback; exhibit integrity and respect for others; and demonstrate clinical competence. They also utilize planning and orienting strategies, possess a broad repertoire of teaching methods and scripts, and engage in self- evaluation and reflection. Drawing upon multiple forms of knowledge, they target their teaching to the learners’ level of knowledge (
      • Irby D.M.
      How attending physicians make instructional decisions when conducting teaching rounds.
      ).
      It is also possible to identify good teachers. Learner ratings of clinical teaching have demonstrated high reliability using as few as a dozen ratings (
      • Irby D.M.
      • Rakestraw P.
      Evaluating clinical teaching in medicine.
      ,

      Marriott DJ, Litzelman DK. Students’ global assessments of clinical teachers: a reliable and valid measure of teaching effectiveness. Acad Med. 1998;73(suppl 10).

      ,
      • Hayward R.A.
      • Williams B.C.
      • Gruppen L.D.
      • Rosenbaum D.
      Measuring attending physician performance in a general medicine outpatient clinic.
      ,
      • Copeland H.
      • Hewson M.
      Developing and testing an instrument to measure the effectiveness of clinical teaching in an academic medical center.
      ). Concurrent validity has been established using objective structured teaching examinations (
      • Prislin M.D.
      • Fitzpatrick C.
      • Giglio M.
      • et al.
      Initial experience with a multi-station objective structured teaching skills evaluation.
      ).
      Nevertheless, little is known about the effects of excellent teachers on student performance in clerkships. The first studies to examine the effect of teaching quality on third-year medical student performance were conducted by Griffith and colleagues (

      Griffith CWJ, Haist SA, Ramsbottom-Lucier M. Relationships of how well attending physicians teach to their students’ performances and residency choices. Acad Med. 1997;72:S118–S120.

      ,
      • Griffith C.W.J.
      • Haist S.A.
      • Ramsbottom-Lucier M.
      Do students who work with better housestaff in their medicine clerkships learn more?.
      ). Teaching quality was based on overall student evaluations; the best teachers were those who received the top 20% of student evaluations, whereas the worst teachers received the lowest 20%. Students exposed to the best faculty and residents performed better on the end-of-clerkship board shelf examination and the National Board of Medical Examiners (NBME) step II subject examination in internal medicine. The best intern teachers increased student skill performance as measured by an objective structured clinical examination. The worst teachers (faculty, residents, and interns) lowered student performance on all these measures.
      Griffith and colleagues (

      Griffith CWJ, Haist SA, Ramsbottom-Lucier M. Relationships of how well attending physicians teach to their students’ performances and residency choices. Acad Med. 1997;72:S118–S120.

      ) studied student performance on a required core medicine clerkship, which at least partially eliminates the problem of being students’ enthusiasm for a discipline, the motivator for both higher teacher rating and student performance. Such a question might arise if a student interested in gastroenterology took an elective in that area and received a high grade for the rotation. Her performance may be more a reflection of her enthusiasm for the subject than of the quality of the teacher. Similarly, the high rating she gave her instructor may be confounded by the student’s enthusiasm for gastroenterology, rather than a reflection of the instructor’s teaching abilities (

      Griffith CWJ, Haist SA, Ramsbottom-Lucier M. Relationships of how well attending physicians teach to their students’ performances and residency choices. Acad Med. 1997;72:S118–S120.

      ).
      Stern and colleagues (
      • Stern D.T.
      • Williams B.C.
      • Gill A.
      • et al.
      Is there a relationship between attending physicians’ and residents’ teaching skills and students’ examination scores?.
      ) confirmed Griffith’s studies. They showed that good teachers have a small but positive effect on students’ learning. In studies of medicine clerks, faculty’s teaching ratings were correlated with students’ postclerkship scores on the NBME subject examination in internal medicine (
      • Stern D.T.
      • Williams B.C.
      • Gill A.
      • et al.
      Is there a relationship between attending physicians’ and residents’ teaching skills and students’ examination scores?.
      ). Surprisingly, residents’ teaching abilities had no effect on student performance, which is at variance with Griffith’s results (
      • Griffith C.W.J.
      • Haist S.A.
      • Ramsbottom-Lucier M.
      Do students who work with better housestaff in their medicine clerkships learn more?.
      ). This may relate more to the choice of the NBME subject examination as the single outcome measure for student performance than to the actual contribution of residents to student education.
      In this issue of the American Journal of Medicine, Roop and Pangaro (
      • Roop S.A.
      • Pangaro L.
      Effect of clinical teaching on student performance during a medicine clerkship.
      ) have taken the next logical step in examining outcomes of clinical teaching—quantifying the relative contributions of clinical teaching to student growth in performance during a clerkship. Instead of just examining outcome measures such as shelf examination scores, the authors developed a growth score by comparing clerkship outcome scores with a combined score for preclerkship grade point average, USMLE step I and a clerkship pretest. They found that the most important predictor of students’ performance on the medicine clerkship was the students’ grade point average in the first 2 years of medical school. Using regression analysis, preclerkship grade point average contributed 28% to the learning outcomes, as compared with 6% for teaching quality. During the clerkship, the resident had the greatest effect on students’ cognitive growth. This makes intuitive sense, as the resident is present with the student more than the attending physician and creates the climate for learning on the wards. It is also consistent with previous findings that excellent senior residents contributed to cognitive gains of students, whereas interns did not (

      Griffith CWJ, Haist SA, Ramsbottom-Lucier M. Relationships of how well attending physicians teach to their students’ performances and residency choices. Acad Med. 1997;72:S118–S120.

      ,
      • Griffith C.W.J.
      • Haist S.A.
      • Ramsbottom-Lucier M.
      Do students who work with better housestaff in their medicine clerkships learn more?.
      ).
      Roop and Pangaro extend our understanding of student cognitive growth in the context of the clinical clerkship experience and provide a “yes” answer to the question of whether teaching makes a difference.

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