Models and approaches

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It is important to plan and prepare for sessions that involve patients. Before the session, think about:

what preparatory work the trainee needs to do (e.g. reading, skills laboratory)
where the teaching will take place
which parts of the teaching session require direct patient contact
whether you will be present or absent when the trainee is with the patient
what role you will take (observer, instructor, demonstrator, questioner)
where discussions will take place and with whom (do discussions always have to be round the patient’s bedside, for example?)
how you will build in opportunities for patient feedback
how you will build in debriefs for learner and patient
what follow-up learning or reading should be carried out.

‘The bedside is the perfect venue for unrehearsed and unexpected triangular interactions between teacher, trainees and patient… physician teachers should be vigilant about grabbing teachable moments’ (Ramani, 2003, p. 114).

Below is a selection of models that might help you to think about and structure learning encounters involving patients.

Janicik and Fletcher (2003, p. 128)

This model groups clinical teachers’ skills into three domains, identifying some of the key aspects that need to be attended to in each domain.

Domain I
Attend to patient's
comfort

Ask ahead of time
Introduce everyone to the patient
Brief overview from primary person caring for patient
Explanations to patient throughout, avoiding technical language
Base teaching on data about that patient
Genuine, encouraging closure
Return visit by a team member to clarify misunderstandings

Domain II
Focused teaching

Microskills of teaching – modified for the bedside

Diagnose the patient
Diagnose the learner
o observe
o question
Targeted teaching
o    role model
o    practice
o    teach general concepts
o    give feedback

Domain III
Group dynamics

Limit time and goals for the session
Include everyone in teaching and feedback

Doshi and Brown (2005, pp. 224–6)

Shadowing (role modelling)	Trainee shadows a more senior clinician and learns by observation Tip – prior to the session identify active observation focus or questions that the trainee will specifically look for
Patient-centred	Trainee is allocated patients and follows their progress from start to end of episode of illness Tip – useful to help trainees actively learn patient management and problem solving; needs support through guided reading and discussion from teachers
Reporting back	Trainee assesses the patients and reports back to the trainer Tip – teacher needs to build in identified briefing and debriefing time with a structure and purpose to the feedback
Direct observation	The trainer observes the trainee’s performance directly Tip – follow rules of feedback, good for learning clinical skills; take care not to leave the patient as a passive participant in the process, think of how the patient might feed back to the trainee
Videoconferencing interviews	The trainee’s interview with a patient is recorded and later viewed with the trainer Tip – needs consent from patient re images; good for learning consultation and communication skills; can be done with a group or single trainee. Take care that the trainee does not over-dwell on minor issues
Case conference	A case is presented by the trainee and discussed by a wider audience Tip – useful for multi-professional learning and inputs; teacher supports trainee re the type of questions that might come up and how to present a case
Wave scheduling (Ferenchick et al.)	This is a technique for including teaching time into an outpatient clinic or GP surgery in which the trainee sees Patient 1 while the trainer sees Patient 2, then the trainer joins the trainee to see Patient 1 and there is a gap in the appointments. This is repeated so that alternate patients (i.e. 1, 3, 5) are seen by both trainer and trainee, and patients 2, 4, 6, etc., are seen by the trainer alone Tip – this is a useful way of optimising busy outpatient clinics but needs careful scheduling, timekeeping and allocation of appropriate patients to the trainee’s ‘list’

McKimm (2008)

A Trialogue is a discussion between three groups with different principles, backgrounds and expectations: a structured three-way conversation (myDictionary.com).

The ‘Trialogue’ focuses on relations and interactions. The relationship and interactions between clinician (as teacher), learner and patient help to explain and structure complex clinical teaching and learning activities.
The Trialogue provides a model for analysing complex interactions between the three ‘players’ in clinical teaching settings through the metaphor of a continually shifting dialogue.
It provides clinical teachers with a framework for:

    – scaffolding learning
    – facilitating learner and patient active engagement in the learning process
    – ‘reflecting in action’ (Schön, 1991) to promote student learning whilst simultaneously attending to the needs of the patient
    - helping clinical teachers to pay conscious attention – ‘mindfulness’ (Epstein, 1999) – to the relationship and emerging dialogue between players.

Trialogue diagram

The Trialogue reflects concepts of the ‘parallel dialogue’ (Gergen et al., 1996) and the ‘inner consultation’ (Neighbour, 2004) suggesting that ‘expert’ clinical teachers (Proctor, 2001) operate within two sets of parallel processes: one attending to the patient (the inner clinical consultation) and one attending to the learner (the inner teaching dialogue).

The modules in this series Facilitating learning in the workplace and Workplace-based assessment provide more ideas relating to specific learning interventions.