Learning and teaching in the clinical environmentBMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7389.591 (Published 15 March 2003) Cite this as: BMJ 2003;326:591
- 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?
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
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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