Pedagogical strategies used in clinical medical education: an observational study

During supervised clinical training, medical students are expected to develop their professional competence and attitudes. The present study investigates how teaching is carried out during medical students' clinical training.

Often the literature declares that clinical medical education adheres to a master-apprenticeship system of learning and the fundamental condition for such teaching is that an expert is teaching a novice [1]. Consequently, in such a system of knowledge acquisition, the clinical teachers play a crucial role as a teacher. According to Lauvås and Handal the master-apprenticeship model focuses the students' ability to handle clinical praxis in accordance with what the clinical teachers believe is correct and what tradition allows [2]. Modelling [3] is central in the apprenticeship model and awareness of being a role model for younger colleagues and students in clinical practice is described among senior doctors [4, 5] and deliberately used by clinical teachers [5].

The master-apprenticeship structure and modelling theory [3] are, however, not sufficient to meet modern academic educational demands. All formal education and academic teaching is aimed towards students gaining new knowledge and skills consistent with what is intended and necessary according to the curriculum. In medical education, as a consequence, everyday knowledge is expected to be left behind in exchange for scientifically-based knowledge or for knowledge based on professional experiential knowledge, useful in professional practice. Students' knowledge acquisition is, from this perspective, understood as a qualitative change from a previous kind of understanding. This means there are qualitative differences in how medical or clinical information is understood. Furthermore, such qualitatively different kinds of student understanding of subject matter may also be found among the students exposed to clinical teaching in a clinical situation. Consequently, we might expect qualitative differences in how something is understood among students. This stresses the need for clinical teachers to identify and take advantage of the students' qualitative differences in what they learn, understand and what they remember of what is studied [6].

Consequently, the way clinical teaching is carried out will have consequences on students' abilities to learn and understand. Ramsden describes three generic ways teachers can understand their role, each of which is related to how students are expected to learn [7]. Ramsden's three methods are: 1. teaching as telling or transmission of knowledge, 2. teaching as organizing student activity and, 3. teaching as making understanding possible. These three methods highlight important qualitative differences in how clinical teachers could consider teaching and student learning [7].

The effective and excellent clinical teacher is described as an: excellent role model; effective supervisor; and dynamic and supportive educator [8]. Kilminster and Jolly claimed that the essential aspects of clinical teaching are that it should ensure patient/client safety and promote professional development, and that clinical teaching has three main functions: educational; supportive; and managerial or administrative [9]. Kernan acknowledged that excellent clinical teaching is multifactorial, transcends ordinary teaching, and is characterized by teachers inspiring, supporting, actively involving and communicating with the student [10]. A number of studies emphasise communicative and supportive competence with the clinical teacher [8, 11–14] and its importance for effective learning [15, 16].

The literature demonstrates a vast number of pedagogical techniques used in clinical teaching [11, 17–21], but there seems to be a lack of studies describing how such techniques are applied and used. In a review, Heidenreich stated that the majority of the teaching methods described were based on theoretical models and/or researcher's personal experience and not derived from empirical studies; and that the literature, to a large extent, is not focused on teaching performance but on the characteristics and behaviour of the effective clinical teacher [22].

One conclusion to be drawn from the literature is that clinical teaching must be seen as a complex learning situation influenced by the learning content, the setting and the actions and interactions of the participants. In order to increase the knowledge concerning clinical teaching, the aim of the present study is to explore how it is carried out in a clinical environment with medical students.

The result of this study shows that the clinical teacher uses a number of pedagogical strategies in clinical teaching, in order to increase the likelihood of student learning. The strategies are entitled; 1) Questions and answers, 2) Lecturing, 3) Piloting, 4) Prompting, 5) Supplementing, 6) Demonstrating and 7) Intervening. These strategies are described below together with selected observational notes in order to support and clarify their meaning.

The clinical teacher frequently made use of these strategies to help the students solve problems or complete tasks. The strategies were used flexibly and could be changed during clinical teaching depending on situation, context and preferences of the clinical teacher.

The aim of this study was to explore how clinical teaching was carried out in clinical education. The study was carried out in several clinical units at the largest teaching hospital in Sweden. By observing clinical teaching and interaction in authentic situations, a more comprehensive understanding of the educational mechanisms of clinical teaching could be reached. The result is mainly built on the observations made during clinical teaching, and the informal interviews were generally used to support the understanding of the observed phenomena. Research from other settings and levels in medical education, would be required to determine whether the pedagogical strategies described reflect a more general way of teaching medical students. More likely is that the pedagogical strategies are related to a number of factors such as students' knowledge level, clinical situation and personal preferences, but also to educational culture at the clinic. Therefore, other strategies might be observed in other settings or situations. We assume however, that the findings demonstrate the importance of attention to pedagogical strategies used in clinical teaching in order to facilitate student learning.

The findings of this study elucidate that clinical teachers used a repertoire of different pedagogical strategies namely: Questions and answers, Lecturing, Piloting, Prompting, Supplementing, Demonstrating and Intervening. Comparable behaviours in clinical teaching have previously been described in the literature [8, 22] For example questioning [21, 22] or dynamic teaching provides explanation, answers questions, giving directions and directing learning [8]. Even the supportive role as a supervisor that gave opportunities for the student to be involved in patient care have been described [8]. Almost all literature focuses on characteristics and behaviours of an effective clinical teacher and not on teaching methods [22]. Few empirical studies have been conducted in order to explore how clinical supervision is carried out in authentic situations. Therefore, this study adds to previous studies by giving empirical evidence of a teaching repertoire used by supervisors in clinical supervision. This result shows that clinical teaching is complex and diversified. In this study we have shown that clinical teaching consists of a spectrum of several teaching alternatives, and is not previously described in this way in the research literature. In accordance with the research literature, the descriptions of the pedagogical strategies also give evidence for clinical teachers' threefold function and role concerning: education; management; and support [9]. In this conclusion we focus on the educational aspect of the pedagogical strategies.

In accordance to Ramsden the pedagogical strategies, can be divided into different superordinate ways of understanding teaching and learning. The strategies bring into the open three underpinning ways of understanding how to teach namely: teaching as telling or transmission; teaching as organizing students' activity; and teaching as making understanding possible [7]. Each of these teaching perspectives has consequences on the teachers' focus in clinical teaching. Figure 1, illustrates the relation between pedagogical strategies, underpinning teaching perspective and the teachers' focus. The illustration should be seen as a continuum, where the pedagogical strategies placed to the left comprise a primary focus on teachers' own knowledge and acting; while the strategies described at the right end of this continuum comprise a focus on students' activity and understanding. These perspectives and focuses will be further discussed below.

The descriptions of the strategies Lecturing, Demonstrating and Intervening are in accordance with the teaching perspectives viewing teaching as Telling or transmission of knowledge [7]. This perspective is the most traditional and common perspective of teaching in higher education, where teaching is seen as a transmission of authoritatative content or the demonstrations of procedures [7]. The teacher is required to be an expert in the subject matter and could be seen as the store of undistorted information. The focus in teaching is on the teachers' personal knowledge and how it can be transmitted efficiently [7]. In applying the strategies, Lecturing and Demonstration the teacher focus was directed toward own acting and knowledge i.e how the subject matter could best be expressed. The students' understanding of the transmitted content was rarely discussed. This teaching perspective could also be linked to situations where it was not possible to allow the students to complete their actions, and the teacher had to Intervene. By Intervening the teacher demonstrated for example the way to act, or the organisational limitations. This could be seen as a transmission of knowledge about a clinical situation or organisational demands. However, by using this strategy, the action planned by the students was often interrupted. Consequently, this strategy could also impair the students' learning process which could result in a deterioration of the relationship between teacher and student.

By Piloting, Prompting and Supplementing the teacher supported the student in taking the role of an active doctor handling the clinical situation and guided the students on how to react. Consequently, these approaches were in accordance with a teaching perspective seeing Teaching as organizing students' activity [7]. In applying this teaching perspective, the focus is moved from the teacher toward the student's activity and the central role for the teacher is to help the student to be active. It is also assumed that by supporting the student in experiencing their acting, learning will take place [7]. For instance, even when the students make errors and experience the consequences of their actions, learning will occur. Learning by experience means that education, like life, is a process of continuously reconstructing experience. The starting point of the activity should be the learner's need for knowledge and the teacher's role is not to control the learning situation, but rather to act as a resource person guiding the situation [26]. It is also assumed that learning how to reflect on what we do and to apply our own knowledge to new situations follows naturally [7]. Improving teaching from this point of view is about extending lecturers' repertoire of techniques [7] i.e. to use the most appropriate strategy/techniques to support the student in acting.

The findings suggest that the clinical teachers' method of support is of great importance and it was essential that the teacher showed sensitivity and stepped in only in a supportive manner, even though their presence and intervention increased several students' confidence (should any potentially harmful mistakes be made with the patient). How important the teacher-pupil relationship is in clinical education is well established [8, 12, 15, 27] not only where examples of effective relationships have proven to enhance learning, but also where examples of poor relationships have compromised a students learning [16].

Another characteristic in these findings was that students' understanding of the clinical situations and actions were rarely discussed or explored by the teachers and, notable during observations was that the individual students seemed to not always understand the consequences and motive of directions and actions. Discussions concerning learning objectives were rarely introduced or called attention to by the teacher. Neither was the content selected to adjust and facilitate understanding by the students. Consequently, the students were mostly left alone to figure out how the knowledge transmitted, demonstrated or experienced could be understood and made useful in other clinical situations. Questions and answers though, could be seen as a strategy that was aimed at making understanding possible [7]. By using this strategy, the focus turned to the students' own understanding of the clinical situation. According to Ramsden teaching should be comprehended as a process of working cooperatively with learners to help them change their understanding. In order to support the students' understanding, the teacher has to focus on how the students apprehend and discern phenomena related to the subject, rather than focusing on what they know about them or how they can manipulate them [7]. Consequently, with a teaching perspective viewing teaching as making understanding possible, the attention is directed toward the learning content, how it should be taught and how it is understood by the student. The teacher should focus on the essential issues that could represent critical barriers to student learning and give such issues special attention. Such teaching also involves discovering students' misunderstandings, intervening to change them and creating a context of learning that encourages students to engage with the subject matter [7]. For example, in supporting the students' use of theoretical knowledge in understanding the clinical situation, or to be able to discern and apprehend the most important information to learn from a clinical situation that might be useful in other situations. Although Questions and answers could be seen as a strategy facilitating and stimulating such a process with the student, we observed that this strategy was not applied in the same way by teachers. Some teachers provided more time for reflection and discussion, whilst others seemed to use this strategy more in order to assess students' knowledge content and level. This latter approach has previously been documented in the literature [8].

The strategies described in this study constituted the learning situation for the student. However, few statements indicated a deliberate use of the pedagogical strategies in order to facilitate learning by the clinical teacher. This is in accordance with other research describing clinical teachers' lack of arguments concerning how learning will best take place in clinical teaching [28]. Therefore, it is more likely that the strategies were learned traditionally and not deliberately used by the teacher.

MSN is a doctoral student in Health Care Pedagogics.

SP has recently defended her thesis for a PhD exam in Health Care Pedagogics.

EP is Professor of Health Care Pedagogics with several years of experience of studies relating to clinical teaching and use of qualitative research methods, for example ethnographic methods.

C-GW is Professor of Education at University College of Kristianstad. He has a long experience of research on learning and teaching in Higher Education and from the application of qualitative research methods.