by Lisa K. Rollins, PhD, University of Virginia
The Liaison Committee on Medical Education has identified accreditation standards
for institutions regarding residents as teachers.1 Yet, residents often struggle to incorporate teaching into a busy clinical service while balancing their own learning needs and service responsibilities. The University of Virginia developed the T-E-A-C-H model for residents through a series of fourth-year medical student (M4) focus groups. M4 students were asked to complete and discuss the following statements related to resident teaching: “I like it when my resident...,” and “I don’t like it when my resident….” We coded the responses and the components of the T-E-A-C-H model emerged from these data. Elements of the model are as follows:
T—Think out loud: Teaching about the clinical decision-making processes is a critical element to medical student education. Yet, discussions in the clinical setting often focus on diagnosis, treatment, and management regimens without explaining the thought process that led to various conclusions or decisions. By thinking out loud, either on the part of the resident instructor or the student, the clinical thought process can become explicit and known to both resident and student. It also can serve as a mechanism to highlight and address areas of clinical uncertainty, an important source of stress for primary care clinicians.2
E—Engage the student: Residents are usually dealing with heavy caseloads and multiple competing demands. As a result, it can be challenging for residents to take time to teach and students may be left on their own to read, or at worst, abandoned. As one student stated, “I can read when I’m at home.” While there are many options one can use to engage students, consider some of the following opportunities to engage medical students:
- Bring the student along—this provides opportunities to model tasks as well as to teach the process side of patient care.
- Teach about process issues as well as clinical content (eg, entering orders, writing notes, obtaining consults, requesting charts from other health systems, coding).
- If an unknown clinical issue arises, the medical student may be able to research the topic and bring information back to the team.
- Identify areas where the student can be involved in the care process. Students want to be involved and to be active members of the team.
A—Ask the student questions: The ability to ask good questions is at the heart of good teaching. It can be helpful to begin interactions with an open-ended question, eg, What do you think is going on with this patient? What did you hear when you listened to this patient? These types of questions can enable a resident instructor to quickly assess the student’s level of understanding. In addition, it can be helpful to ask the student to provide the reasoning behind his or her response, eg, What made you come to that conclusion? What else could be going on? If this was “x” instead of “y,” what would you do differently? What would you do if ...? Otherwise, if the student answers correctly, there is no way for the instructor to determine if the response was a good guess, due to faulty logic, or indeed due to a true understanding of the associated concepts.
It also is important to give the student enough time to respond (at least 5-10 seconds or more). While this simple task may be challenging to remember when everyone is busy, it is important because it may take the student a moment to mentally integrate the necessary information when attempting to answer a higher-level question.3 The process of waiting does two things: (1) it gives the student needed time for cognitive processing, and (2) it lets the student know that you are expecting him or her to take an active role. If the instructor jumps in too quickly, students may quickly learn that they can remain passive in their learning process. Effective questioning helps to keep students engaged and feeling involved in the care process.
C—Create a context for learning: Medical student perceptions of their learning environment tend to decline over the course of their training. In addition to challenges to work-life balance and maintaining student connections, students must also adjust to new teaching approaches in the clinical setting and they often are more inhibited about expressing themselves.4 It may be helpful to consider the following hints to create a positive learning environment:
- Create an environment where the student can ask questions and, if needed, discuss ahead of time how the student should get questions answered in the middle of a busy day of patient care.
- Try not to be judgmental of the student when he or she asks a question, no matter how obvious the answer may seem.
- Try to help the student feel like a part of the team by creating meaningful ways for the student to contribute to the patient care process.
- Take time to get to know the student.
- Treat the student as you would want to be treated. Nobody wants to be ignored, treated rudely, dressed down in public, abused, or be given menial tasks that are unrelated to clinical care.
- Instructors impact the student both by what they say and what they do. It is important to model good professionalism and to curtail derogatory comments regarding patients, colleagues, and other learners. Foster an environment in which all are respected and treated with dignity.
H—Help the student succeed: As part of the educational process, medical students rotate onto different services across multiple specialties. Each setting may have its own set of mores and expectations, and it can be difficult for students to pick up these mores quickly. It is therefore helpful for resident instructors to set clear expectations at the beginning of the rotation. This may relate to performance expectations, expectations around patient encounters, the preferred format for presenting a patient, and the preferred template for notes. Discussing up front what the student needs to do to really shine will help the student, and it will ultimately make things easier for the resident instructor.
Providing feedback is also an important component of this element and it is critical to helping students learn.5 It can be helpful to create the expectation of feedback early so the student does not feel singled out and to provide ongoing and effective feedback, both in written and verbal form. Finally, while attending to the components of effective feedback,6 it also can be useful to solicit the perspective of the student first when providing verbal feedback, as this develops the student’s self-assessment skills, and provides an effective starting point for discussion.
In summary, the T-E-A-C-H model outlines a range of elements that residents can utilize when teaching medical students at their home institutions. Residents are in a unique position as teachers: resident contact time is often greater than attending contact time; residents are often more keenly aware of material that may be perceived as challenging, having recently addressed it in their own training; and residents serve as important role models as they introduce medical students to the culture of medicine. As one student stated,
“Just remember how it was when you were a medical student. We know a lot of facts, but sometimes they aren’t integrated together well and we might not understand the appropriate range of clinical relevance. Think about what you wish you had understood as you were building a clinical foundation, and make sure we understand those issues. That way, we can better help you. Medical students are looking for things to do. They may have a paucity of knowledge in many regards but they want to learn and to be involved.”
- Liaison Committee on Medical Education. Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the MD Degree. Published March 2020. http://lcme.org/publications. Accessed April 28, 2020
- Evans L, Trotter DRM. Epistemology and uncertainty in primary care: an exploratory study. Fam Med. 2009;41(5):319-326.
- Tofade T, Elsner J, Haines ST. Best practice strategies for effective use of questions as a teaching tool. Am J of Pharm Ed. 2013;77(7):Article 155, pp 1-9.
- Dunham L, Dekhtyar M, Gruener G, CichoskiKelly E, Deitz J, Elliott D, Stuber ML, Skochelak SE. Medical student perceptions of the learning environment in medical school change as students transition to clinical training in undergraduate medical school. Teach Learn Med. 2017;29(4):383-391.
- Thomas JD, Arnold RM. Giving feedback. J Palliat Med. 2011;14(2):233-239.
- Ende J. Feedback in clinical medical education. JAMA. 1983; 250(6): 777-781.