What Clinical Teachers in Abstract—In order to identify the components of knowledge that effective clinical teachers of medicine need, the author car- ried out a qualitative study of ix distinguished clinical teachers the context of teaching rounds: clinical knowledge of medicine, pationts, and the context of practice, as well as educational Attending physicians use many forms of knowledge as they listen to case presentations by medical students and residents. This knowledge base enables them to diagnose patients’ problems, assess learners’ needs, and provide targeted instruction.’ What do clinical teachers in medicine need to know in order to teach effectively? Conventional wisdom suggests th knowledge of medicine is all that is necessary to be an excellent teacher. An alternative perspective, articu- lated most frequently by problem- based learning advocates, is that knowledge of teaching skills is funda- mental and that teachers do not have to be content experts. RELEVANT KNOWLEDGE DOMAINS In the context of clinical teaching, which of the perspectives just men- tioned is accurate? Earlier research ‘on physicians’ and teachers’ know!- edge may provide clues to relevant domains of knowledge for teaching. ‘These might include knowledge of subject matter, knowledge of learners, knowledge of general principles of ‘teaching and learning, and knowledge of content-specific teaching. A dlightly diferent version ofthis paper was Correspondence should be addressed to Dr. Iiby, Department of Medical Bducation, HQ-32, University of Washington, Seatle, WA 98195. ‘VOLUME 69 # NUMBER 5 = MAY 1994, DAVID M. IRBY, PhD based teaching Knowledge of Subject Matter “If you understand your discipline, then you should be able to teach it.” ‘This instructional assumption is translated into an often-cited dictum of clinical education: “‘See one, do cone, teach one.” This experiential learning model suggests the close re- lationship between learning, perform- ing, and teaching. Physicians develop an extensive knowledge base of medi- cine and its related disciplines through experience with a broad array of clinical cases. As clinical ex- perience increases, clinical knowledge becomes more tightly compiled and interconnected, Clinical knowledge is, then retained in memory in the form of iliness scripts (clinically relevant information on the enabling condi- tions, causes and consequences of an illness) and instance scripts (recollec- tions of specific patients who suffered from a disease)" Alternative de- scriptions of this knowledge structure are semantic structures,* knowledge representations, and reciprocating rnetworks.® Patel and Groen argue that expertise in medicine involves the de- velopment of adequate knowledge representations combined with the ability to distinguish between rele- vant and irrelevant information in a problem—thereby filtering out irrel- evant material Educational researchers assert that knowledge for teaching requires an in-depth and flexible understanding of subject matter.”"# Teachers need to know their content well enough to make connections within the subject, across disciplines, and with their learners. Alternative conceptions of Medicine Need to Know knowledge of learners, general principles of teaching, and case- scripts. When coi ‘knowledge allow attending physica structional reasoning and to target their teaching to the specific needs of their learners, The results of this investigation are discussed in relation to both prior research on teacher know!- ‘edge, reasoning, and action and faculty development in medi- cine. Acad. Med. 69(1994):233-342. bined, these domains of to engage in clinical in- content help teachers switch back and forth between the student's, the Aiscipline’s, the textbook’s, and their ‘own conceptions.“ Expert. teachers also have richer, more tightly con- nected subject matter knowledge, and more detailed plans organized around content to be taught, than do novice teachers.° Knowledge of Learners Beyond content expertise, teaching involves connecting learners with subject matter. Teachers need to un- derstand their learners’ prior knowl- edge as well as their conceptions and misconceptions of the subject matter. This includes knowledge of students’ typical errors and the nor- mal development path along which students progress in understanding content.%*-!® For example, expert ‘math teachers employ this knowledge to elicit. typical errors and then use those errors in lessons to teach the correct concepts." Teachers’ knowl- edge of learners’ needs, motivations, and abilities also affects tt ing methods. Effective emerges from the interaction between understanding learners and compre- hending subject matter.* Knowledge of General Principles of ‘Teaching and Learning In addition to knowledge of subject matter and learners, teachers possess knowledge of general principles of teaching and learning. Teachers have general conceptions about how stu- dents learn and how instruction ean enhance learning.”® These personal 333theories appear to develop from the apprenticeship of observation (seeing positive and negative examples of teaching) and from the reflective ex- perience of teaching. Experienced teachers also have large repertoires of teaching strategies (e,, lecturing, leading group discussions, asking questions) that can be combined to teach specific concepts. These are general principles of teaching and Tearning because they are not embe ded in specific content, contexts, and learners, Knowledge of Content-specific Instruction ‘When general content knowledge and general teaching methods are trans- formed into content-specific instruc- tion for a particular group of stu- dents, a new form of knowledge results. This is termed knowledge of content-specific pedagogy"® or peda- ‘ogical content knowledge.**** This special form of knowledge unique to teachers develops through the repeti- tive experience of teaching specific content to specific students. The re- sulting knowledge becomes organized into teaching scripts. ‘These scripts are analogous to play scripts that dic- tate the action on stage. Teachi scripts contain general goals of in- struction, key teaching points, specific representations of content (explanations, analogies, examples, learning tasks)? an understanding of the conceptions and misconcep- tions of learners, and procedures learning difficul- 13222 ‘The essence of con- tent-specific instruction is content knowledge organized for teaching purposes that makes it comprehensi- ble to particular learners.*2" ‘This special form of knowledge is what separates teachers from mere content experts. Other potentially relevant domains of teachers’ knowledge might. in- clude knowledge of instructional re- sources.!4825 ‘While a host of observational stud- fes have described the complexiti and challenges of teaching in clinical settings,“ none of them has at- a4 tempted to define the several knowl- edge bases needed for clinical teach- ing and to develop a model of clinical teachers’ knowledge. DEFINING THE KNOWLEDGE BASE OF CLINICAL TEACHERS attempted to create such a model in 1991 by carrying out the study re- ported in the following pages. The ‘method I used was to investigate the knowledge bases for teaching used by six distinguished clinical teachers in general internal medicine, These are the same six teachers described in my previous study about how physicians make instructional decisions during teaching rounds.‘I chose a case-study design using these six carefully cho- sen teachers to illustrate the ‘wisdom of practice” among the best.” I se- lected outstanding clinical teachers rather than representative ones to identify the knowledge of the best ed- vucators, knowledge that is extraor- inary,’ not ordinary. Studying the knowledge of representative teachers could have led to a description of “the fs practices of the unin- "This research strategy fo- ccuses on what is possible rather than what is representative. Thus, my re- search question was “What is the knowledge base for teaching used by distinguished clinical teachers in medicine in the context of teaching rounds?” ‘The teachers I studied were all from the Department of Medicine at the University of Washington School of Medicine in Seattle. They had re- ceived excellent ratings of their teaching from students and resi- dents, and independent nomina- tions by their department chairman and the program director of their d partment’s residency. Further, T lected those who had distinctly differ- ent teaching styles and who were serving as attending physicians dur- ing spring quarter. This group of teachers comprised one professor, two associate professors, and three assist ant professors (four men and two women), ‘The context of instruction was teaching rounds in general internal medicine at two university hospitals, Teaching rounds is a case-oriented in- structional session held predomi- nantly in a hospital conference room with the ward team and is the teacher's primary opportunity to teach medical concepts in the context of patient care. Data were derived from in-depth, semistructured interviews,* a struc ‘tured task involving a think-aloud ex- cercise,®® observations of the ward team, and transcriptions of teaching rounds.*” My interview questions re- lated to the attending physician’s knowledge, instructional reasoning, and actions. The two-hour interviews were audiotaped and transcribed. ‘The structured task involved a think-aloud exercise in response to @ written case describing a medical stu- dent's presentation of a patient with etic ketoacidosis during teaching rounds, The attending physicians wore asked to describe how they would respond to the case, what they would teach, and what problems med- ical students would typically have with this case, This exercise was de- signed to elicit their teaching scripts and knowledge of learners. Twelve medical students on the six teams were also given the case, minus the diagnosis and treatment, and asked to determine the problem, diagnosis, and recommended treatment. This was done to validate the teachers’ knowledge of the learners. observed each team for one week, recording my observations in field notes, and summarizing them imme- diately afterwards, In order to under- stand what was happening during teaching rounds, observations began with, work rounds (when the team consisting of two third-year medical students, two interns, and one senior resident’ review all patients at the bedside) from 8 to 9 Am, followed by an X-ray conference from 9:30 to 10:00 am. and concluded with teaching rounds with the attend- ing physician from 10:30 to 12:00. In addition, all teaching rounds were audiotaped, and one session per at- tending physician was. transcribed. ‘The observations and transcripts of teaching rounds were used to corro- ‘ACADEMIC MEDICINEborate the interview and think-aloud statements. T coded the interview transcripts in order to identify the domains of knowledge needed for clinical teach- ing, and thus construct a model of such knowledge. Preliminary codes were developed based upon Shul- man’s theoretical model of teachers’ knowledge®* and Schmidt's model of physicians’ knowledge.* My i codes were knowledge of clinical med- icine, knowledge of basic sciences, Knowledge of patients, knowledge of smers, knowledge of general peda- form, and pedagogeal convent know: edge. Intercoder agreement was 83% ‘among two doctoral students in edu- cation and myself using a sample of the transeripts.™ The codes were suc- cessively revised as analysis pro- ceeded to account for all of the major themes in the data. The codes changed as categories were collapsed (knowledge of clinical medicine and knowledge of basic sciences became knowledge of medicine, because the informants said that these two cate- gories were integrated), titles of codes ‘were changed to make them more un- derstandable (pedagogical content knowledge became content-specific teaching), and codes emerged from the data (knowledge of context and case-based teaching scripts). ‘The final codes were validated by two gen- eral internists and myself using selec- tive quotes from the transcripts. In- tercoder agreement was 95% among the internists and myself. Final cod- ing categories were knowledge of medicine, patients, context, learners, general principles of teaching, and case-based teaching scripts. The re- sults were then checked against my observations of teaching rounds and the transcripts of rounds. A MODEL OF CLINICAL TEACHERS’ KNOWLEDGE ‘The model of clinical teachers’ knowledge identified by this study is depicted in Figure 1. Below, I discuss each type of knowledge shown in the figure, beginning with a description of the key features of the domain fol- lowed by illustrative quotes from the VOLUME 69 = NUMBER 5 * MAY 1994 Figure 1. The domains of knowledge led for clinical teaching in medi- cine as identified by six distinguished attending physicians in the context of teaching rounds in general internal ‘medicine. In the figure, these domains of knowledge are artificially differ- entiated for emphasis. attending physicians. The teachers’ names are pseudonyms and their comments have been edited slightly for readability. Knowledge of Medicine All of the attending physicians de- seribed the importance of general medical knowledge, referring to it as human biology, clinical experience, judgment and insight, clinical skills, pathophysiology, basic sciences, knowledge of psychosocial medicine, and epidemiology. Knowledge of med- icine is drawn from a variety of disci- plines and incorporates both basic sciences and clinical experience. Dr. Baker describes the medical know!- ‘edge base he uses for teaching pur- po What I know about human biology that is afirmed by clinical experience is what T goletively use for teaching purposes My clinical experience is drawn off bomen biology and allows me to teach ‘people how to uee human biology to take care of thelr patients. There are subsets of humen biology — biochemistry, physi- ‘logy, pathoanatomy —and larger soci tnd environmental issues. There is also ‘relationship between those elements thet determines how well a person with the disease is doing. model of the discipline. He begins at the cellular level, then goes to the causes and manifestations of a dis- ease, treatment options, and the psy- chosocial aspects of the case, and ‘ends with the societal and epidemio- logic context for the disease. “I try to get a sense of all these levels, from the cellular level up to the societal level. 1 use my skills to address the ones that, haven't elready been addressed.” ‘These statements illustrate the broad scope of medical knowledge, the integrated nature of that knowl- edge, and the distinct conceptual schemas of these teachers. ‘The teacher's conceptual framework of the discipline is an important deter- minant_of the content that will be taught. Knowledge of Patients In addition to medical knowledge, these attending physicians possess knowledge of specific patients that they have seen on their services. This knowledge is used to verify clinical diagnoses, to check on learners’ progress, to stimulate the teaching of practical tips on patient care, and to motivate learning. This process en- sures quality patient care and quality instruction, and was described as fol- lows by Dr. Able: Many of the patients I know because 1 hhave sen thom before. They are my own patients, end I have a sense of what the Mory is If T know my patients, then T can’ get at problems in my learners, Dr. Ellis reported, “I get information about the patient through the traine ‘When I go back to talk to the patient, T'm checking up on the trainee to & certain extent.” Knowledge of specific facts about each patient and knowledge of gen- eral principles of medicine are closely linked? and when combined create the attending physician’s clinical cre« bility in the eyes of the ward team, ‘This credibility is critical to the team members’ acceptance of the attending physician's teaching.* 335,Knowledge of Context All the teachers mentioned that knowledge of context affected their teaching. Context includes the pa- tient population served by the hospi- tal, the social context of the patient, the historical context of therapeutic practices, and the context for encoun- tering the patient's story (case pre- nntation versus direct. interaction it mnt). Dr. Charles de- scribed the impact of the patient pop- ulation on teaching: ‘When you ae at Harborview Hospital teaching hospital] certain di lot more common than when the team doesn't tell me that am pro- coating it Dr. Baker observed that students encounter patients in the context of an acute illness and frequently fail to appreciate what precipitates the ill- ness and what follows it. Studies of teachers’ knowledge in other settings have identified knowledge of context as important as well 24021 Knowledge of Learners ‘This domain comprises knowledge of specific learners, knowledge of the ward team as a’ group, and general assumptions about learners by level of training. Knowledge of learners emerges from teaching experience. Dr. Fagan reported, “It is lot less work for you as a teacher if you can figure out where your student is— whoever, the student happens to be... The longer you teach, the easier it is to see where they are.” Dr. Ellis agreed: “Every month I attend I go through a period of trying to figure out where the team is, what their eds are, and what their personali- are like so that Ican interdigitate with them the best.” According to Dr. Davis, Sometimes with a third-year stude you have to go through a problem-o 336 ‘ented approsch to get them to tie tall together in a coherent picture, By the ourth year you expect them to be able to do that. By the time they're interns tnd residents, you should expect them not only to identify the problem but to tunderstand the broader faues, To investigate the accuracy of these teachers’ knowledge of learners, 1 gave each of the attending physi- cians and each of the 12 medical stu- dents a hypothetical case presenta- tion by a third-year medical student, of a patient with diabetic ketoacidosis, (DKA). All 12 students correctly de- fined the problem, identified DKA, and made appropriate treatment rec ommendations. Five of the six at- tending physicians accurately pre- dicted the student’s knowledge and performance; the least. experienced attending physician underestimated the students” ability.) As is true of teachers in other disciplines, these teachers had an accurate knowledge of their learners’ understand- ing 0372139 Tn addition to knowledge of learners by level of training, these at- tending physicians possessed know!- edge of particular students. Thi knowledge is acquired through asking questions and observing performance. “Task students questions constantly. [Pve asked the questions enough times that I know mostly what people can say as third-year medical students,” said Dr. Baker. This general knowi- edge of leamers combined with par- ticular knowledge of specific learners enables the teachers to efficiently and eflectvely dignose learners’ difi- ties. Knowledge of General Principles of Teaching ‘The most commonly articulated gen- eral principles of teaching and the numbers of the six attending physi- cians who described the principles were: actively involve learners and ask lots of questions (6/6), capture attention and have fun (6/6), connect the case to broader concepts (6/6), go to the bedside (6/6), meet individual needs (6/6), be practical and relevant (4/6), be selective and realistic (4/6), and provide feedback and evaluation (3/6). These principles, discussed below, emerged from many readings of the interview transcripts. 1. Actively involve learners (6/6). All of the attending physicians stud- ied conduct highly interactive teach- ing sessions. “Keeping everyone in- volved is my ideal,” said Dr. Fagan. One way to achieve active involve ment and to diagnose learners’ diffi- culties is to ask questions. “I use a lot, of questions to get some assessment of the residents’ and students’ know!- reported Dr. Charles rly, Dr. Baker stated that “ Kind of teaching I like to do is So- cratic, or kind of probing question- and-answer. I ask them questions constantly.” 2 Capture attention and have fun (6/6). In order to make learning mem- orable, teaching must capture and re- tain attention. This is accomplished by using humor, dramatic ease exam- ples, suspense, and enthusiasm. Dr. ‘Able said, “T always try to suck people into having as good a time as T am having.” Dr. Elis emphasizes the im- portance of drama in teaching: “I try to dramatize a point. In a sense, itis making teaching into theater— trying to present things in a way that captures people's attention.” All six physicians studied seemed to enjoy teaching, and they all made learning fun and memorable. 3. Connect the case to broader con- cepts (6/6). Clinical teaching connects learners’ knowledge of the patient's particular problems to a broader un- derstanding of the relevant disease. ‘This helps learners generalize appro- priately from their experience and offers them a conceptual scaffold for building new knowledge. Dr. Baker said: “You draw out something spe- cific from that patient to say [such as] ‘When you are taking care of people like this, you can expect that these will be problems.”” All the attending physicians related the case at hand to underlying constructs of the illness and/or to broader health issues. 4. Go to the bedside (5/6). When students are unable to give a coherent, case presentation, or the diagnosis does not adequately explain the pa- tient’s problems, the attending physi- [ACADEMIC MEDICINE.cians lead the team to the bedside. Dr. Baker, the only teacher who went to the bedside every day during this study, stated, “If don't make a point of doing bedside teaching, it is real easy to just talk and the patient is left out.” When a case presentation is tin- focused, Dr. Charles goes to the bed- side. “The easiest way to determine whether it is a patient or student problem is to go talk to the patient.” Some of the other attending physi- cians went to the bedside to validate physical examination findings and to model and observe interactions with the patient, One attending physician stated that he was uncomfortable teaching in front of the patient, and another said that she perceived bed- side teaching to be an unproductive experience for the team in most in- stances. Thus, neither of them rou- ly went to the bedside as part of teaching rounds—although both of them saw their patients indepen- dently from the team. 5. Meet individual needs (5/6). One of the great, difficulties with clinical teaching is dealing with the diversity of learners’ knowledge and skills. The teachers studied identify the interests of the team members during the first week of the rotation and attempt to meet. those interests during the month, Dr. Davis stated: “I tell them my strengths and weaknesses, and I ask them how I can best help them, So up front I find out who they are, ‘what they want to do, and what their needs are.” Dr. Fagan indicated that she has the same approach: “My job is to figure out what they want to know this month. People don’t learn unless they are ready for it.” Identify- ing learners’ interests and needs helps these teachers discover teachable mo- ments. ‘To meet the diverse needs of learners, these attending physicians ‘use a variety of instructional strate- gies. “The hardest thing about at- tending rounds is bridging all those different levels. I try to do it by hier- archizing knowledge,” said Dr. Fagan. ‘This involves asking students ques- tions about pathophysiology, asking interns questions about. day-to-day treatment, and asking the senior resi dent. questions about broader medical VOLUME 69 # NUMBER 5 © MAY 1994 and health care issues. To meet the unique needs of students, she and the rest of the attending physicians peri- odically teach the students sepa- rately. ‘Teaching rounds are also adapted to the natural flow of patient. care. During this study, four of the six at- tending physicians participated in work rounds (where the team visits the bedside of each patient and makes work assignments for the day) on post-call mornings and shortened or liminated teaching rounds on those days. Post-call mornings occurred every four days following all-night work in the emergency room where the physicians treat and/or admit new patients to their service. During the next two days post-call, discus- sions in teaching rounds emerged out of the most teachable cases. The last day before on-call night was often spent dealing with broader topics and giving more formal presentations. 6. Be practical and relevant (4/6). Clinical teaching must be both prac- tical and relevant. Dr. Baker said that he frames his teaching with this ques- tion to himself: “What practical bits of knowledge have been necessary for me to know about taking care of pa- jents like this? What are the real practical bits of knowledge that need to be brought out about a certain case to get the most learning from it?” Part of the process of being practical ‘and relevant is teaching general con- cepts in the context of specific pa- tients on the service. 7. Be selective and realistic (4/6). ‘These six teachers focused on a few important. teaching points per case, prioritized time among cases to deal with a few cases in depth, and estab- lished realistic expectations for learn- ing during the rotation. “Realizing that the more you say the less people learn, I try to hit two or three themes really heavily during an hour,” re- ported Dr. Charles. “I try to find out where they are and give them the basic skills . . . to teach them four or five things” during the month”, said Dr. Davis. Less is better to begin 8. Provide feedback and evaluation (3/6). “I think feedback is real impor- tant and labeling it as such is also, because otherwise they don't know what they are getting,” reported Dr. Fagen. “Evaluation is an important part of teaching. If you can find out whether somebody is learning, then you can inerease how much teaching goes on,” said Dr. Charles. The pro- cess of giving feedback should be both constructive. and supportive, sug- gested Dr. Fagan: “You have to re- spect the needs of learners and their feelings as people. You should not teach by embarrassment, by pressure, or by berating them.” Dr. Ellis con curred: “I take it as a principle that criticizing people in front of others is not appropriate.” All of these teachers gave large amounts of feedback to the learners. Since it was routinely embedded in teaching, the students frequently failed to perceive it as feedback. In cone instance, I interviewed a medical student immediately following a one- hour meeting with Dr. Charles, who had worked with the two medical stu- dents on their case presentations. ‘This had been an intensive teaching session with a great deal of coaching and feedback. When I asked the stu- dent whether he received feedback from Dr. Charles, he said that he didn’t get much. Since I had just ob- served a great deal of feedback, I was puzzled. So I asked the student what feedback meant to him. He reported that it was the formal evaluation that, he would get at the end of the rota- tion. Clearly there are differences in perceptions about feedback. 9. Other general principles of teach- ing. Individual teachers in this study identified other general principles of ‘teaching, including using repetition, teaching anecdotally with cases, mak- ing things memorable and dramatic, role modeling, and teaching in a style that is right for the teacher. These general principles of teaching offered ‘me initial insights into the next and ‘most important domain of knowledge for teaching, case-based teaching. Knowledge of Case-based ‘Teaching Scripts ‘This domain of teachers knowledge, case-based teaching, is concerned with how attending’ physicians use 37‘cases and case content to teach gen- eral principles of medicine. Under- standing of this domain of knowledge emerged not so much from the inter- views as from observations and tran- scripts of teaching rounds, This form ‘of knowledge involves instructional methods that help learners interpret, reflect upon, and generalize from their cases, For a teacher, this re- quires knowledge of the 'patient’s illness and life narrative, insight Het acres olsen een the case, and relev i scripts, Through repetitive teaching of similar content and cases, teachers develop teaching scripts.}% In this study, the teachers articulated three to five key points that they would teach related to a DKA case.’ Know!- edge of case-based teaching is at the center of teachers’ understanding, where it connects all of the other domains. In the clinical setting, learning begins with a specific patient. In Dr. Baker's words: “The patient is a rep- resentation of an illness and unique features that are examples o type. There are certain characteris- tics of the patient thet cause you to bring out different points about a person and their reaction to illness.” In the context of teaching rounds, several interpretive activities occur. Prior to teaching rounds, the learner elicits the patient’s story. Next, the learner summarizes that story, re- casts it into medical language, and presents it to the teacher and other ‘team members. The attending phy’ cian listens to the case presentation patient's problem and the representation of the case. Then ‘teacher and learners together develop a coherent explanation for the case. Case-based teaching involves (1) helping learners construct coherent representations of the case, (2) filter ing out irrelevant information, and (8) making connections between the specifics of the case and generaliza- tions derived from the medical litera- ture and experience with other patients. selected two very different exam- ples of this form of knowledge in ac- 338 tion to present in this article. Both illustrate how attending physicians use cases for teaching purposes. The first example involves a Socratic or directed-questioning approach to the development of a diagnosis, while the second example was a more presenta- tional style that demonstrates how to communicate with a patient's family. Both come from transcripts of teach- ing rounds. In the first instance, Dr. Baker was responding to a medical student's ‘case presentation at University Hos- pital. After the student gave an ex- tended ten-minute case presentation of a 25-year-old man who had been admitted for persistent epigastr pain, Dr. Baker initiated the follow- ing instructional dialogue about this case: Dr. Baker: Do you think he has ‘acute pancreatitis or do you think hhe has acute recurrent pancreatitis? Is there a difference between the two? ‘Student: I think he has an acute re- current pancre ferences between ‘Number one is the of mild epigastric pain, which ant- acide don't help, and then later the acute and persistent onset. Dr. Baker: Is that an important ‘Student: Yes. I think it is a very important distinction with his tory. Dr. Baker: If itis an important dis tinction, why? ‘Student: looked at the differential diagnosis for epigastric pain . is person with hie surgical the major eauses of pancreatitis is pancreatic insult— which he clearly had twice with an inoma resection and a Inter laparotomy. Dr. Baker: Take a step back to the question: What are two common causes of pancreatitis? Student: Aleohol. Resident: Gallstones. Dr. Baker: Then there i actually a third, which is idiopathic. For the ‘vast majority of cases of acute pan- creatitis, itis one of these three. ‘The older the person, the more likely it is obstructive, and the younger the person, the more likely it is alcohol. The minute you get recurrent pancreatitis, though, the differential changes dramatically. Everything in this ease points to pancreatitis due to surgical compli- cations. The second possibility is that he may have a tumor. Why is ‘that important in this case? Dr. Baker continued this interactive teaching process for another 13 min- utes. He asked more focused ques- tions, provided brief teaching points, quickly summarized what is known in the literature, and assigned readings fon recurrent’ pancreatitis. Through the questioning process, Dr. Baker drew out of the student the key fea- tures of a diagnosis of recurrent pan- creatitis, elicited the underlying rea- soning of the student, and targeted information from the literature to the learner’s point of need. ‘A second example of knowledge of case-based teaching occurred during Dr. Charles's teaching rounds at Har- borview Medical Center (a country hospital managed as a teaching hospi- tal by the University of Washington). An intern presented a case of a 30- year-old man infected with human smunodeficiency virus (HIV), both is mother and his woman compan- jon were asking how long he would live, The following sequence occurred in the midst of a 13-minute discussion of this case: Intern: His girlfriend wanted to know if he would live to be 60 . . . 'm always tempted to say something like, “Well, he may die tomorrow, but may not.” It is hard to know how to respond to that. Dr. Charles: Sometimes, if they are patients that I know well, Pl be pretty frank with them and just give them the statistics, He has AIDS with probable PCP, so that means life expectancy for him on AZT [ACADEMIC MEDICINEprobably somewhere between 18 and 22 months. Fifty percent are dead at 18 months. = Being vague is not Dr. Charles: I think that while he is processing alot of information, that is very appropriate, But when pa- tients are trying to make life plans ‘on what to do in a couple of years, 1 basically say that we have patients ‘that are living four or five years with AZT and we don’t know what ‘their endpoint will be. They may live eight, nine, or ten years. We don't know. So that gives them hope. But, I edd that the average is about two years. Intern: Actually, I may tell him that. I didn't know those num- bers . ‘The conversation continued, with Dr. Charles offering practical and formal Knowledge in the context of dealing with this specific patient. The team ‘was relieved to receive this practical advice, supporting data, and a model of how to share this sensitive infor- mation with the patient and his fam- ily. This style directly addressed the learners’ questions. In case-based teaching, the teacher discerns both the patient’ illness and the learner's representation of the case, and then helps the learner make sense out of the experience. Depending on the circumstances, teachers accomplish this task using Socratic and/or directive styles, The six distinguished teachers made this a highly interactive, engaging, and memorable process. Researchers of classroom teaching describe this form of knowledge as content-specific pedagogy,"® pedagogi- ‘eal content knowledge,¥®* curriculum scripts’ and case-based instruc tions A somewhat similar ap- proach, although oriented towards clinical practice, is the patir tered clinical method, which ai understanding the unique story of each individual patient.“ While recognizing the uniqueness of each patient, case-based teaching scripts VOLUME 69 # NUMBER 5 » MAY 1994 focus on the question: What is this particular patient a case of? How does this person’s unique story relate to stories of other patients with simi- lar diseases and to broader biomedical Knowledge? Other Domains of Knowledge Individual attending physicians in this study identified communication skills (compassion, sensitivity, intu- ition) and knowledge of the curticu- lum (medical school, clerkship, and residency program) as types of knowl- edge essential to clinical teaching. While knowledge of curriculum is part of classroom teachers’ knowledge base,898% this is not generally true’ for the attending physicians studied. Sources of Knowledge for Teaching How did these six clinical educators learn how to teach so well? They ac- ‘quired their knowledge of teaching primarily from the experience of being a learner (the apprenticeship of observation of good and bad exam- ples) and a teacher (reflecting on what worked and did not work). Dr. Able reported that he had taken no formal courses, in teaching methods: “No, none of us have. It’s like sex ‘education and parenting, you just do « [think it is an art, and I think you lear it in an apprenticeship sort of way.” They all stated that exp ence was the biggest determinant of their overall teaching styles, and that they taught in ways that they them- selves like to be taught and that fos tered their own learning. Dr. Davis said, “I draw on my experiences of having been a student and a resi- dent, and try to pick out the things I liked.” Several of them said that it took six to seven years to discover a teaching style that they felt comfort able with. Only two of them had read books and articles on teaching and had. attended faculty development workshops. Dr. Pagan was unusual in having participated in numerous fac- ulty development workshops, semi- nnars, and short courses. IMPLICATIONS ‘Throughout this research, I was im- pressed with the congruence of what I learned about the six teachers’ knowl- ‘edge, reasoning, and action: what those attending physicians told me in the interviews closely matched what they did in practice. This congruence in turn agreed with what their st dents reported and what the tran- scripts of teaching rounds verified. ‘The attending physicians had a rich knowledge base for teaching that ac- curately reflected their own tesching styles and strategies. They were artic- ulate in expressing their insights into teaching and their struggles to con- tinuously improve. These expert teachers used their knowledge in an encapsulated mode—namely, they could give a concise teaching point but when needed or asked could elab- orate on the deeper structure of the knowledge underlying that point, This is similar to the encapsulated knowledge structures of medical ex- perts studied by Schmidt and Boshui- zen‘ and the compiled. knowledge structures deseribed by Bordage and colleagues. The collective knowledge base for teaching identified in this study has for (1) general concep- of knowledge for teaching, (2) facilitating learning in clinical ‘set- tings, and (3) knowledge growth and teaching improvement, Knowledge for Teaching ‘The knowledge base for teaching the six physicians studied incorporates domains of knowledge that, tightly connected through the inte- Scripts. While knowledge of medicine is foundational, it is inadequate for effective clinical teaching. Over time, knowledge of medicine becomes re- organized for teaching purposes and interconnected with other forms of knowledge. While all of the domains of knowl- edge identified in this study are con- ceptually distinct, they functionally overlap. As Dr.’ Able commented when asked to diagram the knowledge 2he uses during teaching rounds: “The domains of knowledge don’t exist in my mind when I am teaching. . . For me it is a fairly cohesive mix.” ‘The most elusive and important form of knowledge stored in memory is case-based teaching scripts. While none of the attending physicians spoke directly to this form of knowl- edge, they demonstrated it during teaching rounds and acknowledged the accuracy of its description in this article. The importance of this com- ponent of knowledge is clearly stated by Hunter: In the clinical context, teaching and learning begin withthe patient. ‘As en interpretive activity .. - under. taken for the eare of sick person, it (medicine) takes the patient as its text and seeks to understand his oF her tmalady in the light of current bio Togica, epidemiological, and paychologi- cal knowledge * ‘The pationt as text is both a unique person and a memorable representa- tion of a general class of disease. After listening to the learner's case presen- tation of the patient’s story, the teacher's task is to diagnose the pa- tient’s problem, diagnose the learner's representation of the case, and connect the learner's under- standing with broader conceptions of medicine and with other cases. This process aids the learner's develop- ment of illness scripts and builds stronger connections among medical concepts. In such an ill-structured domain as medicine, Spiro argues: ‘The best way to learn flexibility cognitive for fature application is ‘case-based presentations which eave “sit in the vari diferent neighboring cases, and. by ‘using a variety of abstract dimensions for comparing cases" Facilitating Learning Case-based teaching strategies sup- port experiential learning processes 40 of students and residents by encour- aging their abilities to reflect upon experience, develop appropriate gen- eralizations, and predict future effects.®°® "This involves three in- structional tasks. First, teachers need to assess learners’ knowledge (includ- ing errors, misconceptions, or gaps in Knowledge) by. asking ’ questions. Other research has found deficits in the content of case presentations! ‘and the tendencies of residents to slant the presentation to what thes think the preceptor expects to hear: Inquiry is essential to overcoming thane clon, Asking questions also has the side benefit of a the learners prior knowledge, which improves subsequent learning *#-# During this inquiry process, teachers need to have a flexible knowledge base, since leamers vary in the ways in which they structure their knowledge. Second, teachers need to organize and present medical knowledge so that learners can comprehend it and use it to satisfy their learning objec- tives. This requires knowledge of case-based teaching scripts to present ‘medical knowledge in an understand- able and memorable manner. This often takes the form of short teaching points, modeling interactions and reasoning processes, and encouraging leamers to elaborate and reffect upon their knowledge. When the latter occurs, subsequent retrieval of the kmowledge is enhanced."” Third, teachers can help learners challenge and expand their existing knowledge. In this instance, teachers need knowledge of medicine, patients, Jeamers, general principles of teach- ing, and case-based teaching scripts. Creative methods may be needed to challenge learners’ understanding in constructive and supportive man- ner, The eight general principles of teaching articulated by the teachers studied (eg, actively involve learners, capture attention, have fun, etc.) facilitate learning, and are con- gruent with prior research on clinical teaching! and with constructivist theories of learning." The empha- sis upon active involvement and the joint construction of meaning in the context of knowledge use capture es- sential features of constructivism. However, the limited number of teachers mentioning feedback is trou- bling although not surprising, While these teachers provided a great deal of feedback to their learners, most. at- tending physicians do not. The lack of feedback during clinical rotations appears to be a rather intractable problem in medical education. ‘Knowledge Growth and ‘Teaching Improvement ‘Through the apprenticeship of obser- vation and reflective teaching prac: tice, attending physicians and resi- dents. may eventually develop a reasonable knowledge base for teach- ing. However, this process could per- haps be expedited through systematic improvement programs for residents and faculty members. In studies of residents’ teaching, resi- dents frequently fail to take advan- ‘tage of teaching opportunities during ‘work rounds and tend to favor lectur- ing over asking questions and actively involving the team in clinical decision ‘making.*** Teaching-improvement workshops are effective mechanisms for developing general teaching skills ‘and for increasing teachers’ and resi- dents’ understanding of leamers.*"- ‘Knowledge of case-based teaching is best learned in the context of depart- mental. teaching-improvement and ‘mentoring programs where content- specific, case-based teaching scripts and strategies can be shared. ‘The present study illuminates the wisdom of practice among_distin- guished teachers in general internal medicine in the context of teaching rounds. Generalizations from this study should be made to theoretical ‘conceptions of teachers’ knowledge rather than to the knowledge base of clinical teachers in medicine gener- ally.**"57 To test this framework of professional knowledge for teaching, further research is needed among less distinguished and more novice clinical teachers, in other medical specialties and in other clinical set- tings. ACADEMIC MEDICINESUMMARY ‘The professional knowledge base of clinical teaching in medicine is multi dimensional. Excellence in clinical teaching requires clinical knowledge of medicine, of specific patients, and of context plus an educational know!- edge of learners, general principles of teaching, and ‘case-based teaching seripts. When combined, these do- mains of knowledge allow attending physicians to engage in clinical in- struetional reasoning and to target their teaching to the specific needs of their learners.* ‘The author gratefully acknowledges the conts- butions of many collegues to the development ofthis study, in particular, Dr, Lee Shulman of ‘Stanford University for his underlying theoret- Jal work on pedagogical content knowledge, Drs, Pamela Grossman and Samuel Winebut ‘ofthe University of Washington for thei uid: ‘ance in qualitative research methods, and Dr. LaAnn Wilkerson of University of California, ‘Los Angeles, for encouraging him to dig deeper into the data, While arming their contribu- tons, the author accepts cole reaponsiblity for the limitations of this peper. References 4. Inby, D, M. How Attending Physicians ‘Male Inatrictional Decisions when Con- ducting Teaching Rounds. Acad. Med. 67(1992):690-638. 2, Norman, G, Ry Brooks, LR, Allen, S W., ‘and Resenthoi, D. 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