Clinical teaching

Clinical teaching is central to health professions education. Learners develop clinical reasoning, practical skills, and professional values through hands-on experience with real patients. Teaching should be aligned with the learners' curriculum and should include a well-defined activity and an effective debrief. This article outlines strategies for high-impact teaching during a range of clinical activities, including shadowing, observed clinical assessment, and case-based discussions (e.g., the “One-minute preceptor”). Specific guidance for procedural skills training is also provided.

• To foster the development of practical skills, knowledge, and professionalism ^[1][2]
• To embed learning in the context of real patients

“To study the phenomena of disease without books is to sail an uncharted sea whilst to study books without patients is not to go to sea at all.” (William Osler, 1849–1919). ^[1]

Clinical teaching engages learners in several key areas simultaneously. ^[3][4][5]

• Cognitive
  • Medical knowledge (e.g., factual recall, application of knowledge)
  • Clinical reasoning (e.g., formulating and evaluating a differential diagnosis)
• Psychomotor and practical
  • Physical examination
  • Diagnostic and therapeutic procedures
  • Oral presentations and documentation
  • Efficient chart review
• Affective
  • Medical professionalism and codes of conduct
  • Communication skills (e.g., patient communication, interprofessional communication)
  • Systems-based practice (e.g., navigating healthcare systems, quality improvement, patient safety)
  • Practice-based learning and improvement (e.g., interpreting medical evidence)
  • Health advocacy (e.g., addressing population health, social determinants of health)

• Preparation ^[3]
  • Establish learners' background knowledge (e.g., observe two minutes of the patient interaction or ask “Have you taken a history from someone with jaundice before?”). ^[2]
  • Consider how the teaching session fits into the curriculum as a whole.
  • Identify learning objectives for the session: See “Key learning domains.” ^[4]
  • Set up the environment (e.g., consider debrief location, obtain patients' consent to participate, and ensure they are comfortable).
• Activity ^[3]
  • Give learners an active and clearly defined task (e.g., assess a patient independently). ^[6]
  • Involve all learners as much as possible (e.g., learners take turns performing parts of the physical examination).
• Debrief ^[3]
  • Give effective feedback: Help the learner identify gaps in their knowledge and/or skills. ^[7]
  • Summarize the knowledge and skills covered, highlighting a specific teaching point (e.g., ask yourself “What one takeaway message do I want the learners to gain from this encounter?”). ^[6]
  • Signpost to relevant topics for self-directed learning. ^[2]

In individual teaching, find time to discuss personal learning goals; determine which areas the learner feels most confident about and decide collaboratively which objectives to focus on in your time together.

Avoid common pitfalls such as misaligning with the learners' curriculum, teaching at an inappropriate level, prioritizing performance over true learning, or focusing solely on knowledge recall instead of practical application. ^[3][4]

Patient encounters in inpatient wards, outpatient clinics, and community settings provide multiple opportunities for clinical teaching. The following recommended strategies can be tailored to the learner and context. ^[1][2][7]

Shadowing ^[6]

When learners observe a patient encounter, consider the following.

• Prime the learner (before the encounter). ^[6]
  • Ask questions to prompt clinical reasoning.
    • Acute symptom or condition: “What causes are you thinking of?”
    • Stable chronic disease: “What complications do we need to check for?”
  • Signpost to highlight a particular aspect of the consultation (e.g., “I'd like you to observe how I share bad news”).
  • Suggest a relevant topic to read before a patient encounter.
• Teach by role modeling (during the encounter). ^[3]
  • Think out loud: Deconstruct the clinical reasoning process.
  • Pause occasionally to check in with the learner.
  • Explain rationale for conclusions.
• Apply clinical reasoning (after the encounter). ^[3]
  • Encourage the learner to outline their thinking process and conclusions.
  • Ask questions that encourage learners to apply their knowledge (e.g., “What if the cough were productive instead of dry?”).

Teaching does not have to take extra time; think out loud as you place an order, write a note, or do a procedure.

Patient assessment by the learner ^[2][6]

When a learner performs a history or physical examination with a patient, consider the following.

• Establish clear expectations (e.g., how long to spend with each patient, how many patients to assess, and when to seek guidance from the teacher).
• Observe a snapshot (e.g., two minutes) of the learner's interaction with the patient.
• Recruit specific patients (e.g., those with hepatosplenomegaly) for bedside teaching to help learners build physical examination skills.
• Conduct case discussions at the bedside.

Always obtain a patient's permission before including a learner in their care, and remember to thank them for participating.

Case discussion

Time-efficient alternatives to a full case presentation allow the teacher to assess and refine the learner's clinical reasoning in a busy clinical environment. ^[2]

“One-minute preceptor” ^[2][3]

• Teacher-led model for concise case-based discussion
• Identifies knowledge gaps and facilitates targeted teaching and feedback ^[2]
• Five-step approach that starts with the learner committing to a diagnosis or plan

“Summarize, Narrow down, Analyze, Probe, Plan, and Select” (SNAPPS) model ^[2]

• Learner-led model for case-based discussion
• Useful for experienced learners (e.g., residents) who are familiar with the SNAPPS model ^[7]
• Six-step process in which the learner:
  1. Summarizes history and findings in a brief, structured presentation
  2. Narrows down to two or three differential diagnoses
  3. Analyzes by comparing and contrasting options
  4. Probes the teacher about uncertainties or alternative approaches
  5. Plans management based on clinical reasoning
  6. Selects a self-directed learning task for follow-up

The SNAPPS model prompts learners to Summarize, Narrow down, Analyze, Probe, Plan, and Select.

This is an ideal approach; apply elements of each component as time allows.

• Preparation ^[2]
  • Gauge the learner’s prior experience and confidence level.
  • Briefly outline the procedure, key steps, and common pitfalls.
  • If possible, use simulation-based training for initial exposure and technical refinement.
• Stepwise skill building ^[3][8]
  • Demonstrate the procedure at a normal pace without verbal explanation.
  • Repeat the procedure and explain each component.
  • Ask the learner to verbalize the steps while the instructor performs them.
  • Allow the learner to perform the procedure under supervision with corrective feedback.
• Active coaching ^[9][10]
  • Ask the learner what should be done next at key decision points.
  • Probe for reasoning behind decisions.
  • Reinforce correct techniques and provide guidance for improvement.
• Reinforcement and supervision
  • Summarize key learning points. ^[6]
  • Adjust supervision intensity based on competence.
  • Encourage self-assessment.
  • Assign peer-teaching roles for reinforcement. ^[10]
  • Give effective feedback.