Inconvenient truths about effective clinical teaching

Abstract

I’ve been teaching clinical medicine for more than 30 years but it seems to be getting harder, not easier. Conventional wisdom in the USA holds that the problem is time and money (or, more precisely: time is money). Hospitalised patients, discharged before doctors can get to know them, are sicker and quicker today. Outpatient teaching is no less awkward, 10-minute offi ce visits and outdated Medicare reimbursement rules gumming up the works. Long overdue restrictions on resident work hours won’t solve these problems. Too little time and money for clinical teaching betokens lack of respect too. Most academic centres in the USA don’t provide adequate support for clinician-educators’ salaries despite substantial government subsidies for postgraduate education. This shortfall is not an oversight; it is a calculated budgetary decision. Insult compounds injury when physician-researchers openly disparage the academic gravitas of physician-educators on the same faculty. This situation raises the obvious question: is clinical teaching today not only more diffi cult but also less eff ective? One might assume that our research-proud profession would know the answer. In fact, despite shocking indictments of the quality, safety, and equity of US medical care, we know little about the eff ect of clinical teaching on learners or patients, nor even how to measure it. Worse, we don’t seem very concerned about this situation. In 2006, four major medical journals (BMJ, JAMA, Lancet, and New England Journal of Medicine) and four medical education journals (Academic Medicine, BMC Medical Education, Medical Education, and Medical Teacher) published a total of one original outcomes study of this kind (which found no correlation between measures of teaching eff ectiveness and patients’ clinical outcomes). Lacking evidence, I do what clinicians do when we don’t have the data we need: I go with my gut instinct. My gut tells me that clinical teaching today—my own and others’—is less eff ective than it used to be and needs to be. Among those who will disagree are many academic leaders and quality gurus who don’t even acknowledge the question. They maintain plausible deniability by looking elsewhere: we need better systems, they say, not better doctors. No doubt they are right about the systems. I propose that the decline of clinical teaching in our training programmes is, like global warming, an inconvenient truth. Even if we saw evidence as eerily convincing as Al Gore’s pictures of melting polar ice-caps, many in academic medicine would look the other way. Rather than take remedial action, we will be tempted to do the greenhouse-gas-shuffl e: blame it on random variation or transient aberration (anything but ourselves) and hope the hurricanes and heat waves just go away. Doubly inconvenient would be to learn that fi xes from the past might not work in the present. For example, due to digital information systems, clinical trainees inevitably review patients’ laboratory data and diagnostic images before they do a history or physical examination. This change portends more than the devaluation of bedside skills; it is nothing less than complete inversion of the conventional diagnostic process. The good news is that innovation in medical education eventually catches up with advances in science and technology. The bad news is that the pace of change is glacial. Worse, we know so little about medicine’s informal curriculum (clinical training) that it’s hard to know where to start. In this spirit, I describe eight habits of exemplary clinical teachers I have known and try to emulate still.