Joshua Bernstein, MD and Sarah Wood, MD

Formal teaching sessions or “didactics” have long been a standard component of clinical education within medical schools. With increasing technology, and an exponential expansion of the content students need to master, medical educators are challenged to adapt their teaching methods to the changing needs of modern learners. There has been a rapid expansion of longitudinal clinical curricula in medical schools throughout the United States and internationally.¹

Programs with students in Longitudinal Integrated Clerkships (LICs) may face challenges of developing effective educational learning opportunities for students who are spending increased time in ambulatory clinics often geographically remote from the central campus. An informal poll of LIC programs conducted at the Consortium of Longitudinal Integrated Clerkships CLIC Meeting in Toronto in October 2016 revealed that most programs continue to invest an average of 4-5 hours per week in formal teaching sessions for students. Review of the literature revealed little published data on how best to utilize formal teaching time. The suggestions below come from a thorough review of the literature, a brainstorming workshop of medical educators at the CLIC Meeting in Toronto 2016, and informal surveys of other programs.

Dedicate the Time
There are many advantages to group collaborative learning in LICs and programs should strive to have students come together for dedicated formal and informal teaching during clerkships.² These sessions provide time for socialization, sharing ideas, and discussing cases interactively. Longitudinal programs may choose to designate a half-day per week as protected time without clinics scheduled as an academic half-day for students. This time can be used to maximize learning using a combination of formal teaching sessions, small group learning, simulations, or student narrative reflection. Sessions should encourage active learning whenever possible.³ Geographic challenges can be overcome using technology such as video conferencing, but whenever possible students should be encouraged to come together in person to enhance engagement and communication skills.

Focus on Cases
There is clear evidence that students prefer case-based learning.⁴ In addition, faculty perceive students as more engaged and involved in their learning when clinical cases are the basis for the teaching, and believe this method improves learning and retention.⁴ However, there is limited data on whether or not this pedagogical method actually improves learning outcomes such as test scores or post-session questionnaires.^5,6 Educators should strive to make didactics case-based incorporating real patients and integrating student experiences whenever possible. Narrative or story based lectures can also be considered and have been shown to be a potential useful tool for learning in medicine.⁷

Use Technology
Technology can be used to enhance learning with computer-based cases, “flipping the classroom”, or using polling software to embed questions or interactive content into teaching sessions. The flipped classroom approach has excellent satisfaction based on student surveys,⁸ but there are pitfalls to consider. Educators should be encouraged to choose learning goals based on competencies and keep pre-session preparation requirement brief and high-yield when possible.⁹ Lecturers should explore the rich possibilities of increasing active learning during the time the group is together with flipped classroom models.

Empower Students
A survey of faculty educators at CLIC 2016 demonstrated a strong consensus regarding the advantages of having students responsible for some aspects of teaching and leading didactics. The literature documents benefits of student led talks not only for learners, but also for student presenters. Students can reflect on their own learning gaps and identify learning goals. Student teachers can use actual patient cases as a basis for didactic talks. A longitudinal curricula provides the unique opportunity for students to follow patients over time, reflect, and share the multidisciplinary aspects of their care including navigating the healthcare system, transitions of care, ethical dilemmas, and other humanistic, socio-cultural, and inter-professional considerations. These experiences can serve as reservoir of teaching topics throughout the year.

Formal teaching sessions will continue to play an important role in medical education providing clinical educators with ongoing opportunities and challenges. As medical education reform progresses, we must embrace innovative teaching methodologies to engage our learners and enhance their learning. Longitudinal curricula are uniquely poised to take advantage of the unique aspects of their programs and develop best practices for dedicated didactic teaching time.

References

1. Worley P, Couper I, Strasser R et al. A typology of longitudinal integrated clerkships. Med Educ 2016;50 (9):922–32
2. Hudson J, Poncelet A, Weston K, Bushnell J, A Farmer E; Longitudinal Integrated Clerkships; Med Teach. 2017 39 (1) 7-13
3. Rideout M, Held, M, Holmes A. The Didactic Makeover: Keep It Short, Active, Relevant. Pediatrics. 2016; 138 (1) doi: 10.1542/peds.2016-0751
4. Thistlethwaite J, Davies D, Ekeocha S, Kidd J, MacDougall C, Matthews P, Purkis J, Clay D; The effectiveness of case-based learning in health professional education. A BEME systematic review: BEME Guide No. 23. Med Teach 2012; 34 (6) e421-44
5. Patterson JS. Increased student self confidence in clinical reasoning skills associated with case-based learning (CBL). J Vet Med Educ 2006; 33(3)426–431
6. Mclean, S. Case-Based Learning and its Application in Medical and Health-Care Fields: A Review of Worldwide Literature. Journal of Medical Education and Curricular Development 2016; (3) 39-49
7. Easton G. How medical teachers use narratives in lectures: a qualitative study.BMC Medical Education. 2016; 16:3. doi:10.1186/s12909-015-0498-8
8. Helen Morgan, Karen McLean, Chris Chapman, James Fitzgerald, Aisha Yousuf, and Maya Hammoud The flipped classroom for medical students. Clin Teach. 2015; 12(3) 155-60
9. Hurtubise L, Hall E, Sheridan L, Han H. The Flipped Classroom in Medical Education: Engaging Students to Build Competency. Journal of Medical Education and Curriculum. 2015; (2) 35-43