IMG_7063

(Listen instead)

Teaching for a good physician is a natural extension of her talents. We teach every day. We teach our patients and their families. We educate our communities. We teach ourselves by reading and synthesizing new information. We cannot be a doctor without being a teacher (it’s what the Latin word doctor means, in fact). For many physicians, the most active time of their teaching is during residency, when they usually have medical students. But teaching, hopefully, becomes a lifelong passion and profession for every physician.

I have had a great deal of success as a teacher and have been honored to win dozens of awards for my teaching over many years. Here are my thoughts on why we should teach and how we should teach to be effective. First though, a couple of my favorite quotes about teaching:

Much that passes for education is not education at all but ritual. The fact is that we are being educated when we least know it. David P. Gardner

A good teacher, like a good entertainer, first must hold his audience’s attention, then he can teach his lesson. John Henrik Clarke

The first question we must answer is, What constitutes good teaching? Let’s start with the end result and work backwards.

Imagine two twin medical students named Alicia and Felicia. Both are on call for the first time on their Ob/Gyn clerkships (at different schools). The next day, they both tweet about their experiences:

Alicia tweets:

Last night was the best experience of med school so far! Delivered my first baby! So happy in med school!! #awesomesauce

While Felicia writes:

I can’t believe I’m paying for this crap. Why even be on call? Thanks a lot. Need an H&P? #thisblows

What happened? What was the difference in the two experiences for Alicia and Felicia? Well anyone who has ever been in medical school can probably guess. Alicia was treated like she was part of the team. Felicia was treated like a nuisance who was in the way of the team. The resident teaching Alicia expected and wanted her to be involved in the care of patients. The resident teaching Felicia tolerated her presence because he had no choice. Alicia’s resident actively prepared her for an opportunity to deliver a baby and made sure she was there on time. Felicia’s resident sent her to the ED while the patient was pushing and “forgot” to call her when it was time to deliver. Both students did an H&P, but Alicia’s resident went over the H&P with her and used it as a teaching tool while Felicia’s resident used it as tool to occupy her time so that he wouldn’t be bothered with her, then, without even acknowledging her work, he dictated it word for word as his own.

Alicia’s resident was enthusiastic and passionate about his job and about sharing that passion with his student. Felicia’s resident was jaded and loathsome. I could go on, but I suspect that both of these residents are familiar already to anyone who has gone to medical school. The simplest answer: Alicia’s resident wanted to teach and Felicia’s did not.

So why should we want to teach? Well, believe it or not, teaching is a selfish act, first and foremost. It helps the teacher as much or more than the learner, at least when it is done correctly.

Teaching gives you the opportunity to consolidate and challenge what you know or what you are learning. If you read something new, teach it to someone the next day. Their questions and the synthetic process of teaching the new information will help you shore up your own understanding and discover any weaknesses in your knowledge. It doesn’t even matter that much if the topic is relevant to the student; the student will still appreciate the time you spent teaching and, in the process, you will model something more important than the facts of the topic: a passion for lifelong learning.

Teaching gives you the opportunity to discover your knowledge deficits. If you allow yourself to be challenged by students, they will discover the limits of your knowledge and understanding. Students come to material with different backgrounds and different understandings. Even teaching the same topics repetitively, but to different students, will serve to expand your depth with the subject. Of course, this assumes that you are interactively teaching and assessing the knowledge levels and comprehension of each student and tailoring what you teach to them. There are some topics that I have easily taught over 500 times, but rarely the same way twice. You’ll benefit from the repetition, too.

Teaching gives you the opportunity for repetition which will aid in your own mastery. Most of my former students assume that I have an eidetic memory, recalling details about studies or topics with ease. But the truth is, my memory isn’t all that good. My trick is only that I have given the same talks hundreds of time, though always a little differently and hopefully with the same gusto as the very first time.

Teaching gives you the platform to grow in knowledge, eloquence, understanding, and authority. It is obvious how our knowledge grows through teaching, but you will also improve in many other ways and these improvements will translate into being a better doctor. Patients value physicians who speak well and confidently about subject matter that they understand. The average intern has a lot to learn about the medical topics they treat. They have a limited depth of understanding. When they speak to patients, they lack confidence and authority. By authority, I mean that the intern is deferential and doesn’t believe herself to be ultimately responsible for the patient’s care. The patient, of course, senses this and the patient-physician interaction is necessarily limited by this.

But teaching medical students allows us to grow in confidence and eloquence. Adopting  the student’s education as your responsibility allows you to grow in authority. Felicia’s resident assumed that someone else would be teaching her and thus didn’t feel obligated to teach her because it wasn’t his responsibility. His probably poor self-esteem and lack of confidence predisposed him to abandon his authority. Accordingly, that resident also assumed someone else would be taking care of his patients, and again didn’t feel the sacred obligation to his patients that is really the hallmark of a good doctor. A good doctor is naturally a good teacher.

Teaching is good for your department and your speciality. If you can increase the happiness of your learners through teaching, you will create a happier, more hospitable and respected rotation and department. If you can increase the enthusiasm of your students for your rotation, you will increase their enthusiasm also for your speciality. In turn you will attract the best and brightest students to your speciality, improving the speciality as a whole. My greatest achievement in academic medicine is recruiting dozens of the best and brightest at my school into my speciality, improving the quality of healthcare for hundreds of thousands of women in turn. The nice thing about enthusiasm and happiness is that they are reciprocal. Happy and enthusiastic students lead to a happy and enthusiastic you.

Ultimately, teaching is good for your patients and your community. Our goal is to improve the health and quality of life for our patients and our communities. You do this by becoming the best doctor you can become by honing your skills while teaching; then, you apply what you have learned to provide the best, most up-to-date, and most compassionate care you can to patients. What’s more, through teaching you will train a generation of even better doctors to replace you.

If you’re sold on the idea of teaching, the next question naturally is, How do we teach? What are the characteristics of good and effective teachers? (If you haven’t, I recommend you read my post, A Tale of Two Teachers.)

Great teachers are humble. Don’t use your knowledge to make others feel inferior, but rather to inspire them to greatness. Realize that your students should and hopefully will surpass you.

Great teachers are patient. Every learner makes mistakes and so did you when you were learning. Welcome these missteps as opportunities to teach.

Great teachers are kind and show respect to students. Contrary to many academic physicians’ ideas about teaching, there is no place for shaming, condescension, belittling, or any other behavior that serves only to swell the ego of a bully. Students will not respect you because they fear you, and your poor self-esteem will not improve because a student ran away crying. What’s more, they will forget your lessons, even if they were good. There is never a reason to not be kind and respectful.

Great teachers have enthusiasm for the subject. We have talked about this already, but learners love passion. If you are not passionate about what you do, well, that’s a whole different problem. Let students share in your passion.

Great teachers show, not tell. The traditional, tired, didactic lecture is ineffective and uninspiring. Generation Y students in particular will lose engagement in less than 7 minutes. Engagement is crucial. There are lots of ways of doing it, but you have to engage students and captivate them. Teaching is 90% showmanship.

Great teachers learn from their students and love learning. Just acknowledging that you can and will learn from your students already makes you a good teacher. How many people deliver the same lecture, period after period, year after year, decade after decade? Unfortunately, too many teachers just ‘phone it in’ with the same old lecture that they have been delivering for the last several years. The lecture might have been great 8 years ago, but in today’s fast-paced and ever-changing world of medicine, it’s already out-of-date. Your students and your patients are being disadvantaged if you don’t think fresh each time you deliver a lecture, updating not just your facts but your style. That student who you think is being disrespectful on her phone while you are talking? She is actually reading the newest information since you didn’t bother to update your presentation.

Great teachers are positive; they smile; they have charisma; they are genuinely caring. Remember Alicia’s teacher and Felicia’s teacher? Guess which one was doing these things? Alicia’s teacher genuinely cared for her and wanted her to succeed. Felicia’s teacher couldn’t care less. The greatest piece of advice for any doctor is to actually care about your patients and their outcomes. Everything else will follow. The same is true for teachers. Actually care for your students and their outcomes, and everything else will fall in place.

Great teachers engage their students. Engagement is about more than just keeping the learner’s attention while you preach. Good engagement helps the teacher assess the student’s level of knowledge and understanding. It helps the teacher assess the learner’s attitude. Then the great teacher can tailor the lesson for the individual student. Every student is different and the best way of teaching each student depends on where they are in their development; engagement is the tool that allows us to find that out.

Great teachers have high expectations. To me, this is one of the most important points of all. We do more harm by assuming that students are not exceptional than by any other act. Realize that anything you think that you know or think that you can do – that 25 year old person sitting across from you will know more and do better. Part of your job as a teacher is helping the student develop his own self-efficacy. You don’t do this by being condescending and having low expectations. You do this by showing him that you believe in his ability to understand and do whatever is in front of him. Expect the best from your students; they will surprise you.

Great teachers provide a receptive environment and allow mistakes. If you expect the best and aim high, students will fail. But in this failure is the greatest of all opportunities to teach the lessons that really matter.

Failures, repeated failures, are finger posts on the road to achievement. One fails forward toward success. C.S. Lewis

Share your own failures with students. They will respect you even more. You will teach them the secret lesson of greatness: Everyone fails, but the ones who are undeterred by failure, and learn from it, are the ones who succeed in the end. Failure should be our teacher, not our terminus. Great teachers embrace a student’s failings with encouragement and nurturing support. If you haven’t already, I suggest you read my post, Teaching Adult Learners: Lessons from Yoda.

So we have talked about characteristics of great teachers, but now we must ask the question, What makes for great teaching? 

To answer this question, I will unashamedly borrow from one of my favorite papers on the subject, Twelve Tools for Teaching Medical Students by Selzer and Ellen. The 12 tools are theirs but the commentary is mine. In some cases, I have used their tool differently than they did. I recommend that anyone who teaches medicine for a living read their excellent paper.

  1. Viva la difference. There’s not a right or wrong way to teach and there’s no best personality for it either. Embrace your personality and be genuine. This is your best chance of connecting. We have all had lecturers who tried to do something innovative that they learned at a conference and it fell flat because it felt artificial and contrived. Do what works best for you. Don’t conform.
  2. Clear objectives. Having clear objectives and expectations of students is absolutely paramount. Good objectives let students know which points are most important to remember for later tests, but they also allow the student to leave a teaching session feeling accomplished. Objectives and expectations are even more important in the clinical setting. Don’t assume that students know what is expected of them. Tell them clearly. Never criticize or negatively evaluate a student for not doing something that you didn’t clearly tell him to do. The number one complaint of bad teachers and bad courses are ill-defined objectives and expectations.
  3. Analogies and metaphors. The best teachers are masters of analogies and metaphors. They allow the teacher to use what the student already knows to draw parallels to new concepts. For example, “A miduretheral sling stops the flow of urine like stepping on a garden hose with your foot stops the flow of water.” Extended analogies can be a powerful teaching tool that students will remember. Hundreds of times I have explained the pathophysiology of uteroplacental insufficiency and its treatment by talking about submersing a student underwater in a swimming pool. More on that later.
  4. Popular culture and current events. Anytime you can use current news events or popular culture to make a point, you again will tack onto something students already know and they are more likely to remember it. A conversation about elective cesarean delivery might start with Britney Spears or a discussion of the BRCA gene mutation might include Angelina Jolie.
  5. Use their knowledge. Teaching students how to use what they already know, albeit slightly repurposed, is empowering. For example, in the clinical years, always start with the basic sciences and bridge forward to the clinical sciences. If you are making a differential diagnosis for toe pain, have the student tell you what they know about the normal anatomy of the toe first, then have them explain to you how pain is perceived, etc. Finally, have them disrupt this normalcy however they like to cause pain. The differential will now include things like spinal cord tumors, and that’s okay. The point is to get them to use what they already know. I also like to engage students about anything they personally feel competent about. I may ask them to teach me something about a subject they are really good at; everyone is good at something. What follows may be a conversation about water skiing or cooking; it doesn’t really matter. But the student feels empowered by realizing that she is a competent person who can master, and teach, something.
  6. Technology. The internet has democratized information. Use it. Your students will whether you choose to or not. Point them to excellent YouTube videos, TED Talks, Wikipedia articles, or other resources. But also don’t let technology get in the way. PowerPoint is more often a deterrent to good learning than a contributor. Keep your tech simple and purposeful and think of lectures as conversations with friends.
  7. Clinical tales. Connecting your teaching point to a real clinical story is powerful and allows you to humanize an otherwise dry bit of material. Clinical stories also allow you to teach much more than just the facts; you can illustrate mistakes that you made and lessons you learned. Retelling, in real time, how you solved a problem or how the story unfolded is a wonderful way of providing deep, contextual learning.
  8. Be affective. Don’t hesitate to display the variety of emotions that accompany being a real physician. We deal with triumphs and tragedies in clinical medicine; sharing the range of emotions that befit such stories will help your students’ memories while maintaining their engagement.
  9. Be interactive. There are many ways to be interactive. I favor the Socratic approach but it’s certainly not the only effective way. However you do it, you must constantly interact and engage students.
  10. Make them the doctor. Treat students as if they are the physician at all times, particularly in the clinical setting. The most powerful lessons come when the student feels that she is ultimately responsible for the patient’s care. Remember Felecia? She probably felt like she was merely shadowing or observing, but Alicia felt like she was important to the team. Make sure they are fully engaged in the role of the physician – both the good and the bad.
  11. Make it simple for students. Many teachers drown students with too much knowledge and too much depth before the student is ready. Assessing the learner’s level of knowledge, and then building on it, is always the best approach. The good teacher doesn’t need to show off his knowledge with esoteric and inconsequential trivia or brag about his former victories. Teachers with poor self-esteem often do this to feel superiority over the learner. Don’t. Instead build a solid foundation of simple facts and explanations and then add on at appropriate times.
  12. Get feedback. You will only grow as a teacher if you solicit and respond to feedback from students. Students are your audience. Their perceptions of you matter. Don’t make excuses for poor evaluations. Even the greatest of teachers can improve. I would add to this last point that a great teacher also gives feedback. Feedback, done well, is an important opportunity for teaching.

What are some the pitfalls or impediments to teaching students? There are an ample number of things which might derail the well-intentioned teacher. Most are just excuses. Be honest about them with yourself when they come up. For example, you might find that you don’t teach because you aren’t provided time/money/resources to teach. This is an excuse. The real problem is that you don’t have a passion for teaching. Don’t blame the system. Teachers sometimes feel that they cannot trust learners with their patients or that their patients don’t want students. These are excuses as well. When done well, the majority of patients welcome well-supervised students and most enjoy them for what they contribute to the encounter. Teachers often feel that there just isn’t time to teach, but this is usually due to inefficient utilization of the student. There is always a way. In fact, the busier you are, the happier and better experience the student will usually have. The point is, don’t make excuses for not teaching; rather, make teaching a priority and understand its importance to you, your practice, and your patients.

What are some effective venues for teaching? All of them can be. Play around. Be flexible. Some inspiration:

  • Traditional lecture (requires extensive preparation)
  • Mini-talk (limited prep time)
  • Set aside time (e.g. attending or resident rounds)
  • Back to bedside (some prep)
  • Computer-assisted (some prep)
  • Spontaneous, ad hoc (maybe no prep)

He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all. William Osler

Clinical teaching ultimately requires clinical time. All of the theory and simulation in the world cannot, in the end, take the place of seeing real patients. We do have to balance the demands of teaching with patient care. But there are definitely effective and creative ways of doing both, so that the two activities complement and enhance each other. One method is The One Minute Preceptor. The One Minute Preceptor consists of 6 steps designed to structure the interaction between the teacher and learner:

  1. Get a Commitment
  2. Probe for Supporting Evidence
  3. Reinforce What Was Done Well
  4. Give Guidance About Errors and Omissions
  5. Teach a General Principle
  6. Conclusion

If you’ve read this far, thanks. I am passionate about teaching and you probably are too.

To conclude, here’s ten simple things that I would recommend you take away from all this and utilize on your way to becoming a successful teacher of medical students:

  1. Remember what it was like to be a student (and don’t repeat the mistreatments you experienced).
  2. Engage and be kind to students.
  3. Tell them what you expect of them (and what they can expect of you).
  4. Always give them the benefit of a doubt.
  5. Ask them what they need and/or want to learn.
  6. Have mini-lectures always ready.
  7. Talk to them about what you are reading.
  8. Narrate to them your thoughts while working up a patient or your steps during surgery or procedures.
  9. Let them do stuff.
  10. Give them feedback (in private).

Do just these things and you will be a fantastic teacher.