Inpatient teaching can be chaotic, erratic, frustrating, and demoralizing, as students of varying levels of sophistication and interest fight off (or surrender to) interruptions and urges to sleep, while the attending physician holds forth on unanticipated topics, and about patients who may not be available. Or, it can be riveting. Students and residents learn, and everyone, including the attending physician and even the patient, comes away educated and enriched. What accounts for the difference? Perhaps the difference is bounded not strictly by the teaching but, rather, by the extent to which the teaching responds to learning. Does the teacher follow a fixed internal lesson plan, deaf to the student's responses and readiness to learn? Or does the teacher listen, take cues from the student, and appreciate that teaching has value only to the extent that it facilitates learning? Molding teaching to learning will not provide foolproof guidelines; not enough is known about learning to allow for rules; and what is “known” is rarely evidence-based. But that is not to say that the field of learning is without powerful and useful ideas.
Of these, at least four are particularly germane to inpatient teaching (). The first two have to do with knowledge. Knowledge is developed not by accumulation of facts, like so many coins in a bank; rather, it is acquired by extending and revising previous knowledge. It is constructed, like a ramp or a bridge. New ideas take on meaning in a coherent relation to old ideas. Conventional approaches to education view teaching as telling, knowledge as facts, and learning as memorization. In place of that, inpatient teachers might consider a different model of instruction in which teaching is enabling, knowledge is understanding, and learning involves not memorization but active construction.1,2
Inpatient teachers who hold to this second model find themselves asking fewer questions such as “What is the most common cause of anemia?” and more questions like “What do you think is going on?” Or, “Why do you think that?” Or, “How does that fit with what we talked about yesterday?” They scaffold new ideas around old ideas, build on learners’ existing concepts, and encourage them to construct concepts that are more sophisticated and powerful.3
From Principles to Practice
Ultimately, of course, knowledge is valuable if it can be used to solve problems. The second idea, related to the first, is that in solving problems experts rely on their repertoire of case-based solutions.4
Success solving cardiac problems fails to predict success solving rheumatologic problems. Medical expertise tends to be specific to subject and case, and not readily transferable across different types of cases.5
It is contextual, that is, it is related closely to the circumstances in which the knowledge was acquired.5
Knowledge acquired in a classroom may not be readily available for use at the bedside; whereas knowledge acquired at the bedside, particularly knowledge related to a specific case, should be available when a similar case is encountered. Clinical expertise depends less upon generic problem-solving skills and general knowledge, and on more specific experiences in realistic settings.6
None of this would have surprised Osler, who insisted that students be taught “on the wards.”7
Nor would it have surprised Samuel Bard, the 19th Century physician who urged, “The student must see, and hear, and feel for himself. The hue of the complexion, the feel of the skin, the luster and languor of the eye, the throbbing of the pulse and the palpitations of the heart. Where can these be learned but at the bedside of the sick.”8
At the bedside of the sick students acquire knowledge in the context of actual cases.
The discussions that accompany cases serve several purposes. According to Schulman, they are occasions for offering theories to explain why certain actions are appropriate, and so they are useful for teaching principles; they function as precedents for practice and illustrate how problems are solved; and they allow students to learn how to “think like” doctors.9
Cases are messy. Rarely do they admit a single right answer. Thus, they are ideal for initiating novices into worlds that require judgment and thought. Whether case discussions should occur at the bedside, conference room or both will be considered later on. Here we simply underscore the importance of making attending rounds case-based and giving attention to case-based discussions.
The notion of discussion leads to the third major idea about learning which is at once simple and complex: for learning to occur students must be involved, or even better, they must be personally invested in the learning process. Teaching, therefore, requires not only a knowledge of subject, but a knowledge of how students learn and how they can be engaged. Fundamentally, teaching is about creating the conditions in which students agree to take charge of their own learning, individually and collectively.1
Inpatient teachers, therefore, have the responsibility to create settings in which students are comfortable taking risks, making mistakes, and even saying, “Hmm ..., I don’t think I understand.”
Faculty may recall wistfully their own experiences as learners in which the setting was far from secure; scary may be a more apt description. Such memories tend to be vivid and, in fact, there are data to suggest that recall improves as a function of stress.10
But inpatient teaching should be about more than recall. The goal of inpatient teaching should be to get students to “work” with the material, to reflect on it, and to feel comfortable enough with it so that at some future point it can be summoned up and used.
This leads to the final major idea, which is that learning of this sort is possible only if the rounding team functions as a community. A learning community is one in which the surroundings support rigorous, intellectual analysis and collaboration, in which a series of understandable guidelines that define roles and responsibilities are negotiated and shared, and in which participants treat each other with respect.1
For inpatient teachers, the notion of the rounding team as community has several important implications. The first is that a month of rounds should begin with an implicit but also an explicit understanding of roles and responsibilities. Interestingly, the first-day orientation to attending rounds, though often omitted, makes the list of teaching behaviors that students value most.11
Beyond that, it now should be considered required. The aforementioned ACGME Special Requirements call for “The program director [to] prepare explicit written descriptions of lines of responsibility for the care of patients on each type of teaching service and [to] make these clear to all members of the teaching teams.” The Special Requirements go on to stipulate that “Residents should be involved in creating and revising the [curriculum] document, and the program-approved document should be distributed to and discussed with all residents particularly as they start new rotations.”12
Another implication of the concept of a learning community is that, yes, there need to be leaders but, no, they need not be supreme. Daloz13
writes of the importance of balancing credibility, the characteristic of the teacher who generally is assumed to be correct, with authenticity, the admission that no one has the answers all the time, not even the attending physician. Credibility makes students perk up, while authenticity reassures them that the attending physician is human, even “just like me.” When no one is always right, no one needs to fear being wrong. Students then begin to take risks and to rise to the teacher's challenges.
Challenge works best when it is coupled with support.13
Inpatient teachers can provide support when they know who their students are, what problems they face, their weaknesses and their strengths, and what makes them tick. Christensen and coworkers write, “Our knowledge of students helps us to meet them ‘where they are.’ And that is where learning begins.”1
In unstructured settings like inpatient teaching, there is nothing so practical as a good theory. The four principles identified in may help inpatient teachers to develop personal theories about the essence of inpatient teaching. From these theories can come actual practices, some of which are listed in and described more fully below.