What Do Learners Want From Their Teachers?

Several studies based in ambulatory clinics or hospital wards have identified what learners—medical students and residents—believe are characteristics of good teachers. Those meta-analyses of the characteristics of effective clinical teachers and their teaching methods revealed that educators take on several important roles: effective supervisors, dynamic teachers, role models, supportive helpers, and successful planners and resource users [1, 2]. These roles shift in preference depending on the learner’s level: medical students generally prefer traditional instructors (teachers who control the environment), whereas residents more frequently describe good teachers as those who are supervisors and supportive of their autonomy [3].

From each specific educational experience, learners value those who teach with enthusiasm, state answers and objectives clearly, offer opportunities for problem solving, and provide true mentoring [4]. A focus group of internal medicine residents identified a set of characteristics for “skilled” bedside teachers, arguably the most frequent type of instruction readily available in an ED. They concluded that faculty members who had the ability to conduct timely, efficient, and beneficial bedside instructions for a variety of learner levels, and were unafraid of the barriers to bedside teaching, had the greatest success in this particular medical setting [5].

Studies of EM learners mirror these findings. A focus group of students, residents, and off-service intern ED rotators developed several consensus principles of effective teachers: those who seize the teachable moment, give appropriate feedback, are learner centered, have a good attitude, and are good role models with effective teaching skills [6]. The teacher’s level of training (resident, junior staff, or senior staff) was found to be unimportant if teaching was tailored to the learner’s needs. Other educator characteristics that EM learners value include efficiency, organization, knowledge base, adaptability to barriers, and respect for patients [7].

Learner preferences also differ by generation. An assessment of EM intergenerational differences found that younger trainees (most of today’s students and residents) have a more informal learning and interpersonal style and expect individualized, timely feedback and guidance in each educational encounter [8]. They prefer direct, well-defined expectations and consequences and small-group or interactive settings with focus on patient care.

What Do Medical Educators Believe are the Characteristics of Great Teachers?

Historically, medical education has progressed “on the shoulders of giants”; that is, each generation of teachers learns from those preceding it. Only in recent times has serious studies been conducted to investigate why great teachers were considered great and how they imparted their knowledge and methods to their students. With the premise that all teachers are learners first, several studies on accomplished physician–educators have investigated how these instructors achieved success. The influence of positive role models was stated unanimously; this is particularly important because many teachers receive little or no formal educational training or supervision [9, 10]. Institutional encouragement, recognition, and promotion of formal and informal teaching and establishing dedicated time strictly for education are also seen as critical for the development of excellent medical educators. However, time constraints and support for educational endeavors vary widely among settings and may be particularly challenging in international EM departments.

Medical educators across specialties have proposed characteristics of an “ideal” medical teacher: someone who is stimulating, encouraging, competent, communicative, and knowledgeable [11]. Great teachers possess both cognitive (academic or methodologic) and noncognitive (personal or relational) attributes that contribute to success [12, 13].

In a survey of accomplished (award-winning or highly promoted) EM teachers, several strategies were identified that contributed to a superior learning experience. In short, these educators believed that all the following contributed to their educational success: learner-centered activity, tailoring teaching to the situation and environment, acting as a role model with a good attitude, and efficient use of all available resources [14]. The greatest success comes to teachers who focus their information on the needs and levels of the learner, create an environment in which expectations are clear and mutually agreeable, and show active involvement in patient care. These educators also suggest that having different teaching strategies on hand for any situation, for example, busy or slow times, day or night, with solitary students or a mixed group of learners, allows them to deliver a consistent product regardless of the circumstance.

Synthesis of the research described earlier on both EM- and non-EM-based learner and educator preferences reveals several core truths (Table 20.1). Perhaps, most appropriate to the ED, educators who take time to teach—or “seize the teachable moment”—without fear of the many barriers to instruction are highly valued by learners. Enthusiastic teachers who are learner centered and patient centered in their approach deliver the highest-quality educational experience. This places demands on the educator in regard to how to tailor instruction to a wide variety of learner backgrounds and styles. The best teachers are able to provide instruction in an efficient, organized manner. Perhaps the most important, but also least tangible, requirement for great teachers is that they act as positive, enthusiastic role models with an excellent attitude. These approaches maintain the time-honored tradition of mentoring medical professionals as an important function in modern education.

Table 20.1 What do learners and educators think makes a great teacher?

Learners	Educators
Learner centered	Learner centered
Role model	Role model
Ability to “seize the moment”	Ability to “seize the moment”
Enthusiasm/positive attitude	Enthusiasm/positive attitude
Efficient and organized	Direct involvement in patient care
Overcomes educational barriers	Adaptability
Strong knowledge base

What Styles and Strategies Do Great Teachers Use?

In the constantly changing environment of the ED, great teachers marry a set of tried-and-true teaching styles with the current needs of the learner group and the demands of the circumstances at hand. Strategies that promote excellent learning have been developed for both formal and informal education settings. Because the settings vary, teachers must also be flexible in their personal style—alternatively authoritative, collaborative, suggestive, or collegial—as appropriate to the situation.

Formal Teaching Settings

Teachers can choose among several lecture styles to convey information. The oldest and most common of these in medical education is the didactic lecture. In this format, the teacher conveys his or her knowledge directly to a group of learners, with little interruption from questions or interactive discourse. Although this is a common and efficient strategy used in medical education, it is not applicable in a busy ED [15].

An interactive style of teaching, with a steady flow of questions and answers between teacher and learner, is more engaging and often more appropriate for the ED. To stimulate learning, superior educators are skilled at maximizing the yield from a series of focused questions. These teachers ask clear, targeted questions appropriate to the learners’ levels; allow for multiple correct responses; use queries that require more sophisticated thought than a simple yes/no; and, perhaps most importantly, allow sufficient wait times (3 s or more) for a response [10, 15].

In addition to strict lecture and questioning styles, EM teachers may have opportunities to provide direct demonstration of a particular technique or procedure to students and residents. This may seem time consuming and inefficient, but experiential learning has been shown to be quite effective in learning and applying new knowledge or physical skills [16]. This demonstrative style can ultimately foster the autonomy of learners because it introduces them with a standard skill set that they can then work to improve.

Informal Settings

By necessity, much of EM teaching takes place at the bedside. Despite challenges, this environment meets learner and educator goals for patient-centered on-the-go adaptable teaching. A model of best bedside teaching practices has been proposed and provides strategies for three distinct domains: patient comfort and involvement, focused teaching, and group dynamics [17]. First, permission is asked of the patient and after it is granted, all learners are introduced. The primary caregiver provides a brief overview, and the case is discussed with clearly defined teaching points. Throughout the experience, patient understanding is ensured and a team member follows up individually with the patient to clarify misunderstandings. After the bedside encounter, focused teaching applies the microskills model (described later), role modeling, and practice. Both the goals and time spent are limited, and all members are included in teaching and feedback.

The microskills model of clinical teaching (Table 20.2) provides a framework for structuring the educational experience described previously [18]. The first two tenets of this model are learner centered: “get a commitment” (allow the learner to present and commit to solving a particular case or problem) and “probe for evidence” (analyze the learner’s reasoning so that gaps in knowledge or thought process can be ascertained). The educator then teaches “general rules,” which are standardized bits of knowledge targeted to the learner’s level. Finally, the teacher “reinforces what is right,” that is, supports accurate knowledge, and “corrects mistakes” by discussing errors and how to prevent them in the future. By remaining learner centered, this model gives learners what they seek, enables great teachers to deliver a consistent experience, and can be practiced informally at the bedside or elsewhere.

Table 20.2 The microskills model of clinical teaching.

Get a commitment

Probe for supporting evidence

Teach general rules

Reinforce what is right

Correct mistakes

Another popular strategy for informal clinical teaching is to have a set of well-rehearsed “teaching scripts” on hand that can be applied to various cases [4, 19]. Great educators choose their teaching cases wisely and focus on those that will maximize learning broad concepts.

An expert opinion describes the “WALK the TALK” strategy of clinical teaching, which synthesizes learner and educator preferences with practical applications of bedside teaching styles (Table 20.3) [20]. Educators seize the moment in an interactive, patient-centered, hands-on manner, in which clinical uncertainty is seen as a teaching opportunity rather than as a barrier. Students are led through the process, rather than simply reporting the outcome, of medical decision making in a way that promotes self-directed learning and efficiency of communication. These core practices were reiterated in a survey of teachers and students in the ambulatory setting, where involving and stimulating learners and offering clear expectations with skillful patient care significantly predicted overall teaching effectiveness [21]. This approach may be especially useful in the international setting, where formal teaching time may be constrained, but bedside opportunities for informal education remain plentiful.

Table 20.3 “WALKing the TALK” for effective clinical teaching.