Clinical Teaching Reexamined Frank T. Stritter, Ph.D., Jack D. Hain, Ph.D. and David A. Grimes, M.D. Abstract—In an effort to determine the most effective clinical teaching behaviors of clinical teachers or preceptors in individual or small group settings, investigators at the University of North Carolina and the University of Alabama developed an instrument to survey all clinical medical students at the two institutions. This process resulted in a compilation of the specific behaviors found to be most helpful to the responding students in facilitating their clinical learning. All items were then factor analyzed, resulting in six more general teaching dimensions or factors being identified. There were active student participation, preceptor attitude toward teaching, emphasis on applied problem-solving, a student-centered instructional strategy, humanistic orientation, and emphasis on content and research. The more specific behaviors which loaded on each factor were also examined. An essential element of medical education is the teaching that occurs in clinical settings. This teaching has traditionally taken place in university hospitals and has been the responsibility of full-time faculty members or residents and part-time fac- ulty members under the supervision of the full-time faculty. This clinical teaching can be defined as that which occurs in an in- dividual or small-group setting, generally at the bedside but also in ward rounds and in small seminars. In recent years medical ‘This paper was adapted from a presentation at the ‘Thirteenth Annual Conference on Research in Medi- cal Education November 12, 1974, during the AAMC. 85th Annual Meeting, Chicago. Dr. Stritter is an associate professor in the Univer ‘of North Carolina School of Medicine, School of Education, and School of Public Health at Chapel Hill; Dr, Hain is director of the Division of Educa- tional Measurement and Research at the University of Alabama School of Medicine at Birmingham: and Dr. Grimes is 9 resident in the Department of Obstetrics and Gynecology at the North Carolina Memorial Hospital in Chapel Hill. education has been increasingly conducted outside of the traditional university hospi- tal setting in satellite campuses or in community hospitals and offices removed from the university. Volunteer and part- time clinical teachers, who do much of the teaching in these locations, have ques- tioned the nature of effective clinical teach- ing. In addition, house staff and new clinical faculty members generally occupy positions that require that they impart clinical knowledge and skill to medical students, and most have had little formal contact with teaching except as recipients. In contrast to elementary, secondary, and collegiate teaching, less attention seems to have been directed toward char- acterizing effective teaching in medical school, particularly at the ctinical level. Therefore, the investigators determined to ascertain what effective clinical teachers do that makes them effective. Studies have previously been reported which describe 876Clinical Teaching/Stritter et al. some type of “expert observation of a variety of clinical and other instructors (1,2). Other investigators have described perceptions of what has worked well for individual teachers in a variety of clinical settings (3-5). Still others have ventured to ask the “real experts,” the students, what they felt to be effective clinical teaching (6,7). Coombs and Boyle (8) reported that the most popular courses in medical school are those in which the faculty members are enthusiastic and convey a sense of impor- tance to the material, organize lectures well, and manifest genuine interest in stu- dents. Miller and his associates (9) advised the medical teacher to set an example, be patient, ask problem-solving questions, re- view cases, and encourage critical think- ing. Holcomb and Garner (10) discussed the elements of effective instruction by describing several general pedagogical principles and implying their applicability in any teaching-learning situation. A major difficulty of these and other studies that were reviewed, however, is that the characteristics identified and recom- mended tend to be so broad as to be of limited utility in attempting to improve teaching practices. The individual de- sirous of learning to be a more effective clinical teacher would not find an abun- dance of concrete advice. The present investigators, therefore, de- cided to approach the recipients of the clinical teaching, the students, and inquire of them which behaviors characteristic of clinical teachers make a difference in fs itating student learning. Recent reviews of the literature (11) supported this approach by concluding that student ratings of teaching are generally valid and reliable. The overall purpose of the study described here, then, was to add to what is known by attempting to answer the following survey question: What specific behaviors or teach- ing approaches of clinical teachers do 877 students feel contribute most to their learning? Study Design From a thorough review of relevant litera- ture on instructional theory and sugges- tions from experienced teachers, many items were derived describing those clin- ical teaching behaviors which might be in- dicative of effective clinical teaching. Studies such as that by Hildebrand and his colleagues (12) were most helpful in this regard. Items were selected from the list for the scale to be used in the study that were (a) defined in behavioral termi- nology, (6) related primarily to instructors’ interactions with students, (c) appropriate for clinical instruction, and (d) not particu- larly reflective of the individual instruc- tor's knowledge of his subject area. Some behaviors felt not to describe effective teaching were also added. Four medical educators assisted in de- termining the validity of the behaviors by responding to a draft. Each individual examined the list that had been deyeloped in some detail, adding additional behaviors and modifying existing ones. A pretest was conducted when the scale was reviewed by a representative group of senior medical students belonging to the University of North Carolina chapter of the medical honorary, Alpha Omega Alpha. This proc- ess contributed rly and resulted in a list of items totaling 77. The items were then organized into a questionnaire; a five-point scale format was derived: and the question was posed as to whether cach teaching behavior contributed signifi- cantly, moderately, somewhat, or not at all ilitating student learning of clinical medicine. Respondents were asked to as- sume relatively equal content expertise on the parts of the preceptors, Responses were assigned weights of 1, 2, 3, or 4878 Journal of Medical Education according to the degree of favorableness assigned that behavior by each respondent. The scale was distributed to all third- and fourth-year medical students at the Uni- versity of North Carolina and all third- year medical students at the University of Alabama in the winter of 1973-74. These were all the ical students then enrolled at those institutions. A total of 265, or 83 percent, of the total group responded, indicating the general student concern for the topic. The item means and standard deviations for the two groups were nearly identical; therefore, the two samples were combined for the purpose of data analysis. Results The rating data from the questionnaires were analyzed in two ways. In the first approach, means and standard deviations were computed for each of the 77 items. The items were then rank ordered accord- ing to ascending mean values and small- ness of deviation in order to identify what the students felt to be the most effective clinical teacher behaviors or characteris- tics. Table I presents the 16 behaviors rated as most helpful in descending order. This table indicates that students perceive that the most effective clinical teacher approaches teaching with enthusiam, dy- namism, and energy. He identifies what he considers important; that is, he sets objec- tives for his students, and he summarizes major points. He teaches for comprehen- sion and problem-solving rather than for factual recall. He encourages students to raise questions: and he explains, clarifies, and provides precise answers. He provides students with opportunities to practice a variety of skills and abilities and provides feedback to them in a constructive fashion. Characteristic of all behaviors is the pre+ ceptor’s demonstration of a genuine inter- est in students and an accessibility for student concerns and questions. VoL. 50, SEPTEMBER 1975 Further analysis of the data was under- taken in an attempt to identify and analyze dimensions or structures of effective clini- cal teaching which underly the more spe- ic behaviors. Intercorrelations were computed among the 77 items of the questionnaire, and dimensions were de- rived by employing a centroid factor anal- ysis of the intercorrelation matrix; this was followed by a maxplane rotation of factors having eigenvalues greater than 1.0 (13). Six factors were obtained. Table 2 presents the names given to the six factors and, for each factor, the average of the means and standard deviations of student responses to congruent items loading on and subse- quently defining that factor. In the table the factors are ranked in descending order according to this mean value. The mean value for each factor or dimension was interpreted as reflecting the dimension’s relative importance in the clinical learning process as perceived by students. Also listed are the items representing, specific teaching behaviors that loaded signifi- cantly on each factor, thereby defining the factor, and their corresponding loading values or factor coefficients. Factor | is composed of items which suggest that the most effective clinical teacher provides a personal environment in which the student is an active participant. Items loading on this factor indicate that the effective preceptor willingly remains accessible to his students and that he provides time for discussion. He encour- ‘ages students to raise questions, and he is careful to answer questions raised to the best of his ability. He develops opportuni- ties for students to practice their technical and problem-solving skills, and he explains the basis for his own actions and decisions. Factor 2 was interpreted to reflect a positive preceptor attitude toward teaching and students. Items loading highest on this factor indicated that the effective precep-Clinical Teaching/Stritter et al. 879 TABLE | MEANS AND STANDARD DEVIATIONS OF SIXTEEN CLINICAL TEACIING BEHAVIORS IDENTIFIED aS Most HELPFUL By STUDENTS Behaviors Answers carefully and precisely questions raised by students Approaches teaching with enthusiasm Explains the basis for his actions and decisions Provides students opportunities to practice both technical and problem-solving skills ‘Surnmarizes major points Corrects students when wrong without belitling Demonstrates a genuine interest in students Strives to make difficult concepts easy to understand Emphasizes conceptual comprehension rather than mere) fuetwal recall Willingly cemains accessible to students Provides competent patient care Approaches his teaching with dynamism and enerey Prepares well for rounds and other contact with students Explains lwcidly Identifies what he considers important Discusses practical applications of knowledge and skills Meant sD. 13 6 14 5 1a 6 6 14 6 1a 7 1a 7 14 a ly La 7 1a a 1a a 1s a 15 a 1S a 15 a 1s 7 * Based on a scale of one = significant contribution, two = moderate, three = somewhat, and four = none. tor is friendly and outgoing and conveys his enjoyment of dealing with students. He demonstrates a genuine interest in students (and in patients). He approaches teaching with enthusiasm, dynamism, and energy. Factor 3 reflects that the next most effective teaching behavior or process the preceptor’s concentration on the clini- cal problem-solving process rather than on factual material alone. Items loading on this factor reveal that this approach in- volves giving every student a chance to discuss practical application of his knowl- edge and skill and an opportunity to practice and apply problem-solving ap- proaches rather than solution per se. The preceptor expects students to employ con- cepts to demonstrate comprehension and ‘emphasizes conceptualization and compre- hension by stressing topics of broad applicability and by drawing upon data from related fields. He is concerned about clinical judgment rather than simply recall of facts and information. Factor 4 suggests a student-centered instructional strategy or approach, Items involved in this factor indicate that the instructor defines realistic learning objec- tives for his students, and he systematically assesses and advises students of their prog- ress. He rewards students for good per- formance and is sensitive to their personal needs in the learning situation. Factor 5 includes items which suggest that the effective preceptor is humanistic in orientation. He is interested in personal ‘and social aspects of patients in relation to their illness, and he has pleasant and cordial relationships with students and hospital staff. He is sensitive to individual patient needs and encourages students to share their feelings, values, and experi- ences in learning clinical medicine. Factor 6 reflects preceptor emphasis on references and research. The items loading on this factor suggest that, in this dimen- sion, the instructor emphasizes his per- sonal research and research of others. He demonstrates a broad reading in his own specialty, and he cites important refer-TABLE 2 Factor Coserictents, MEA THE SIX DIMENSIONS OF CLINICAL TEACHING BEHAVIOR Dimensions Meant SDt I. Active student participation Ls on Provides time for discussions and questions Answers carefully and precisely questions raised by studefits Willingly remains accessible to students Explains the bases for his actions and decisions Provides students opportunities to practice both technical ‘and problem-solving skills Encourages students to raise questions . Preceptor attitude toward teaching 16 02 Conveys his enjoyment of associating with students Demonstrates sensitivity to patient needs Deals with students in a friendly, outgoing manner Demonstrates a genuine interest in students 3. Emphasis on applied problem-solving 17 02 Stresses topics of broad applicability tot students Requests that students employ conccpts to demonstrate comprehension Involves every student in practice opportunity. that is, gives every student a chance Draws upon data from related fields, for example. radiology. sociology. epidemiology, in considering problems Discusses practical applications of knowledge and skills Emphasizes conceptual comprehension rather than factual recall Emphasizes problem solving approaches rather than solutions perse 4, Student-centered instructional strategy 1802 Defines realistic objectives for students Assesses student progress systematically Advises students oftheir progress regularly Demonstrates sensitivity to student needs, for example, help with feelings of inadequacy. frustration ‘Compliments students for good contributions, observations, or performance Humanistic orientation 22 02- Stresses social and psychological aspects of itIness Encourages students to share his knowledge and experience Demonstrates sensitivity to patient needs Recognizes and greets students even when not onduty together Advises students effectively on nonmedical problems when approached Deals with hospital staff, for example, nursing personnel, in friendly outgoing manner 6. Emphasis on references and research 25 06 Cites important references Occasionally challenges points presented in texts and journals Reveals broad reading in his medical speciality Describes research he has done himseif when appropriate Emphasizes his personal research * Derived by averaging the values of all i + Derived by computing the standard deviation of the mean ofthe means. 880 5. AND STANDARD DEVIATIONS FOR THE VARIABLES COMPOSING Factor Coefficient 0 8 61 56 B2 st 68 65 63 62 63 ay 58 ST 35 52 2 a 6 61 8 52 ot 50Clinical Teaching/Stritter etal. ences, occasionally challenging points in source materials. While the items in this factor have a mean value reflecting that this process is helpful, the students viewed it as clearly less beneficial in the learning process than the previously described five dimensions of teaching behavior. ‘Conclusions Although the criteria for the values as- signed to the specific teaching behaviors and the more general teaching factors or dimensions are the students’ perceptions of what helps them to learn most effectively and are not based on student achievement, the investigators believe that several useful points have been identified. It is not sur- prising that the most significant factor was the students’ desire to be an active partici- pant in the learning process, which reflects their concern about the more typical teacher domination of the process. The student respondents may have been react- ing to that particular teaching characteris- tic in calling attention to their feeling that what the student does may be most impor- tant in his tearning in contrast to what the teacher does. Both Miller and associates (9) and Holcomb and Garner (10) in their respective handbooks for medical school faculty members discussed that point but did not emphasize its importance as strongly as the students seemed to in re- sponding to this study questionnaire. The investigators have determined that this study has several logical extensions. Among those presently planned are: 1. Replication of the study involving more respondents; additional measures of validity; and other, more sophisticated ‘analytical methods. 2. Development of a process by which a clinical preceptor can analyze his own teaching behavior with primary considera tion of improving the learning of his students. 881 3. Development of a reliable and valid scale or evaluation form which can be used by individuals, departments, and/or insti- tutions in assessing the quality of clinical teaching for a variety of purposes in their respective spheres of responsibility. 4. Development of a workshop in cal teaching which might assist physicians who have newly assigned teaching respon- sibilities, for example, new house staff, volunteer or part-time instructors from the community, and other new faculty mem- bers, considering some effective ap- proaches. This is an initial study that has served to identify several behaviors and factors im- portant in effective clinical teaching. Be- cause it is a first attempt, the investigators recognize that it is not complete and that some essential behaviors may have been inadvertently overlooked. Nevertheless, they believe that this study has added to the approaches that can be considered by the physician who may be nearing clini- in an individual or small- group setting for the first time or who may just be desirous of improving what he is already doing. References se » F.E, and Obserat in of Under- Action. J. Med. Educ. 39:147-168, 1964. 3. Ross, J. P. On Teaching By Example. Surg. Gynecol. Obstet... 127:1317-1319, 1968, 4, Fietp, M. Student Growth and the Clinical Teacher. J. Dent. Educ..35:306-307, 1971. 5. Excet, G. L. Care and Feeding of the Medical Student, J.A.M.A., 215:1135- 141, 1971, 6. Cotsoxas, N. J.. and Kaiser. H. F. ‘Student Evaluation of Clinical Teaching. J. Med. Educ., 38:742-745, 1963. 7. Metz, R., and Hagin, O. An Apparent882 Journal of Medical Education Relationship Between the Seniority of Fac- uly Members and Their Ratings as Bed- side Teachers. J. Med. Educ., 41:1057- 1062, 1966. 8. Coons, R. H.. and Bovie, B. P. The Transition to Medical Schook: Expecta- tions Versus Realities. In Psychosocial Aspects of Medical Training. Coombs, R. H.. and Vincent, C. E. (Eds.). Spring- field, Iinois: Chasles C Thomas, 1971, Pp. 100-103. 9. Muter, G. E. (Ed), Teaching and Learn- ing in Medical School. Cambridge, Massa- chusetts: Harvard University Press, 1961, Pp. 137-145. 10. Houcoms, J. D., and Garver. A. E. Vow. 50, SepremBer 1975 Improving Teaching in Medical Schools. Springfield, Ulinois: Charles C Thomas, 1973, Pp. 154-163. 11. Costix, F., Greesoucn, W. T., and Mexats, R. J. Student Ratings of College Teaching: Reliability, Validity and Useful- ness. R. Educ, Res. 41:511-535, 1971. 12, Hieoemeaxp, M., Winsox, R.C.. and Diexst, E.R. Evaluating University Teaching, Berkeley: Center for Research and Development in Higher Education, University of California, 1971. 13. Harwax, H. H. Modern Factor Analys Chicago: University of Chicugo Press, 1967,