Clinical Review ABC of learning and teaching in medicine

Learning and teaching in the clinical environment

BMJ 2003; 326 doi: http://dx.doi.org/10.1136/bmj.326.7389.591 (Published 15 March 2003) Cite this as: BMJ 2003;326:591
  1. John Spencer

    Clinical teaching—that is, teaching and learning focused on, and usually directly involving, patients and their problems—lies at the heart of medical education. At undergraduate level, medical schools strive to give students as much clinical exposure as possible; they are also increasingly giving students contact with patients earlier in the course. For postgraduates, “on the job” clinical teaching is the core of their professional development. How can a clinical teacher optimise the teaching and learning opportunities that arise in daily practice?



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    Clinical teaching in general practice

    Strengths, problems, and challenges

    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. Professional thinking, behaviour, and attitudes are “modelled” by teachers. It is the only setting in which the skills of history taking, physical examination, clinical reasoning, decision making, empathy, and professionalism can be taught and learnt as an integrated whole. Despite these potential strengths, clinical teaching has been much criticised for its variability, lack of intellectual challenge, and haphazard nature. In other words, clinical teaching is an educationally sound approach, all too frequently undermined by problems of implementation.

    Common problems with clinical teaching

    • Lack of clear objectives and expectations

    • Focus on factual recall rather than on development of problem solving skills and attitudes

    • Teaching pitched at the wrong level (usually too high)

    • Passive observation rather than active participation of learners

    • Inadequate supervision and provision of feedback

    • Little opportunity for reflection and discussion

    • “Teaching by humiliation”

    • Informed consent not sought from patients

    • Lack of respect for privacy and dignity of patients

    • Lack of congruence or continuity with the rest of the curriculum

    Challenges of clinical teaching

    • Time pressures

    • Competing demands—clinical (especially when needs of patients and students conflict); administrative; research

    • Often opportunistic—makes planning more difficult

    • Increasing numbers of students

    • Fewer patients (shorter hospital stays; patients too …

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