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.
1. Questions and answers
This strategy is observed when clinical teachers ask questions in order to activate the students; make them discuss and describe how to deal with medical problems; and management specific to the patients. The teachers' point of departure is the students' reasoning in combination with their own preferences in the main focus of the clinical problem. The teacher occasionally made a conclusion, summarizing the student's thoughts and argumentations.
A patient with kidney problems is discussed.
Teacher: On the x-ray, it's hard to tell the difference between pus and fluid. How do you figure out what it is?
The student picks up the sample test has a look and answers.
Teacher: He has low creatinine, why?
The teacher and student further discuss what the cause of the problem could be.
Teacher asks: What is it we want to know? What do we want an answer to? What do you want to know about the kidney's function? What do you look at then?
Student answers. The teacher nods and confirms. The teacher ends the discussion by saying that we may possibly talk to the urologist about this patient (I (clinical teacher, see table 2). 20 (observation, see table 1)).
The teacher also permitted the students to ask questions and relate these to the teachers' reasoning and actions. There were also examples where a student's question was returned by the teacher with the comment: The problem and solution are now your responsibility.
Using this strategy, the teacher created a dynamic process where the clinical teacher and students shared newly encountered experiences with previously acquired knowledge and experience.
The strategy sometimes took the form of an examination. For example, in one situation a teacher asked: What is a hernia? How long will the patient be on sick leave? The questions asked were based on what the teachers considered most important to understand. The teacher would supplement with knowledge they considered crucial, which could result in lecturing.
By asking questions and observing students' behaviour, the clinical teacher could assess students' level of knowledge. In cases where students showed a lack of knowledge, the teachers' intention changed from questioning to lecturing about the actual area of knowledge. Lecturing could also occur if teachers observed errors in any areas or a deficit in students' behaviour or reasoning. Lecturing took place frequently throughout the teaching session and examples of the strategy included: defining the meaning of medical terms; explaining symptoms of illnesses and localisations; and surgical and medical treatments. The clinical teacher clearly explained what areas of medical treatment required the most attention. Lecturing not only included medical theories and facts, but also, implicitly, medical attitudes and guiding principles in problem solving: for example, how to act and communicate with patients in consultation. The observational note below illustrates such a situation.
The clinical teacher clearly and precisely describes the procedure a doctor should go through when examining and talking to a patient who has an interpreter present. The teacher explains what to think about and how to conduct oneself with both the patient and the interpreter (A, 1).
The meaning of this strategy is that the clinical teacher uses guiding questions, statements or signals to ensure the student pays attention to and focuses on specific content in order to reach an expected or previously decided goal. By piloting, the teachers prevent students from getting stuck in the management of a particular task. The teachers used guiding statements, invitations or questions in order to make them continue what they were doing. The students acted according to the teacher's directives, but the students' understanding and reasons for their actions were not discussed and there was no request for critical thinking or understanding from the teacher. Easing the student's actions by piloting does not necessarily lead to the intended perception or increase of knowledge. Students acted according to the teacher's directives without discussing the meaning or intended goal. In such situations there was no request for critical thinking or understanding from the teacher. Consequently, by piloting, the teachers guide the students around the difficulties in a clinical situation. The observational note below illustrates piloting when discussing postoperative management. In this situation the teacher directs the student in what to focus on, in order to get the postoperative management completed and done.
The medical student prescribes fluids. The nurse writes this down. The teacher nods consent.
The teacher says: We should take tests.
(Then the tests were prescribed by the teacher)
The teacher continues: What about an analgesic?
The student asks how much the patient should have (H, 19).
Piloting could also be used by the clinical teacher when they aimed to place students in a situation where they were expected to develop their understanding or/and experience-based knowledge. A situation which often occurred was that the teacher pointed out that students should meet and talk with the patients before making any judgments concerning treatments or assessments. In this situation, the teacher seldom specified or discussed what they wanted the student to learn or experience. Consequently, when piloting was used it was difficult to know whether the meaning was understood by the students.
This strategy is characterized by the clinical teacher prompting a student to prevent the student "losing face" in front of the patient or other personnel. This approach is similar to piloting, but the focus of using prompting is found in the process. By prompting, the teacher supported the student in, for example, communication with a patient; whilst using piloting, the purpose was to direct the student to the correct answer or action. Accordingly, by prompting, the teacher supported the student in adopting the role of doctor. This approach was observed in situations where the students appeared to need help in their assessment, problem solving or in communication with patients or nurses. The teacher provided advice and/or directives by prompting. One illustration of this is described below.
The teacher is standing away from the bed. The medical student seems unsure if the wound appears to be healing and subsequently looks at the teacher. The teacher whispers to the student: The wound looks like it's healing fine.
The medical student then relays this to the patient (H, 3).
This approach is characterized by clinical teachers' supplementing during students' communications with patients or other personnel. The strategy is characterised by the teachers either adding some complementary important facts, or in some cases completely taking over the student's communication. This strategy demands teachers' sensitivity and awareness in deciding whether students are in need of support to handle a situation, otherwise loss of face is inevitable.
The student greets the patient. The student sits on a stool in front of the patient who sits on the bed. The teacher stands nearby and listens while the student talks to the patient. After a while the student signals (by looking at the teacher) that she has nothing further to say. The teacher then nods and brings the conversation to an end (A, 1).
In this particular case, the student signals that she does not know how to deal with the situation entirely. The teacher notices this and supports the student by helping her with what has to be said. In other cases the clinical teachers assessed the students' ability to deal with the situation and found it necessary to step in and supplement in order to continue the consultation, sometimes together with the student.
With this strategy the clinical teacher demonstrates how to act, assess, communicate, and perceive a problem. This is demonstrated when teachers deliberately illustrate how to act or what to focus on, by displaying the correct behaviour in a clinical situation; for example when communicating with patients, or in assessment or evaluation. The observational note below describes such a situation.
Instead of the teacher telling the student what to ask the patient, the teacher does it himself and palpates the patient's abdomen, whilst the student observes (E, 14).
Demonstrating also included situations where the clinical teacher facilitated student perception of the learning object (seeing, hearing, listening or feeling). The purpose was to illustrate and create a perceptual understanding of a physical phenomenon. For example by evoking or pointing out medical phenomena or symptoms as described in the observational note below.
At ward rounds the teacher examines a patient with a fluid filled abdomen. The teacher says: Look here (the teacher then does a vibrating motion with his hand on the abdomen) do you see the wave motion in the abdomen? When it looks like this, there is a lot of fluid in the abdomen (F, 17).
The strategy also covered the clinical teacher taking the patient role, in order to clarify typical symptoms. Another example of demonstrating can be found in the operating room, where students were encouraged by the teacher to increase their awareness of the structure and abnormalities of an organ.
Significant in this strategy is the teacher taking an authoritative role, interrupting the student and taking over the situation. In intervening, the clinical teacher focuses on getting the assignment completed. The observational notes below describe one situation where a teacher uses this strategy.
At ward rounds one of the medical students, who is in charge of the patient, asks; "may I look at the wound?", and the patient says, "yes of course." The medical student asks both the patient and the teacher by looking at the teacher. As a result, the teacher responds and takes over the consultation, leaving the medical student feeling somewhat "excluded". The medical student looks at the teacher who subsequently assumes complete control of the consultation (B, 3).
Significant in the above situation is the student's actions being interrupted when the clinical teacher intervenes and takes over. The student has to stand aside and assume the role of an observer. Using this strategy, patient management, organisational demands and limitations were demonstrated to the student. We observed that the students could thus experience a lack of feedback resulting in a lack of explanation and diminished understanding of their actions and how they managed the situation. Sometimes they felt "excluded" and their knowledge undervalued.