Papers from the 9th Cambridge Conference

Clinical teaching: maintaining an educational role

for doctors in the new health care environment

D Prideaux,1 H Alexander,2 A Bower,3 J Dacre,4 S Haist,5 B Jolly,6 J Norcini,7 T Roberts,8

A Rothman,9 R Rowe10 & S Tallett11

Context and objectives Good clinical teaching is central clinicians can apply their skills to the effective man-
to medical education but there is concern about agement of learning resources. Similarly skills as ad-
maintaining this in contemporary, pressured health care vocates at the individual, community and population
environments. This paper aims to demonstrate that level can be passed on in educational encounters. The
good clinical practice is at the heart of good clinical clinicians' responsibilities as scholars are most readily
teaching. applied to teaching activities. Clinicians have clear roles
Methods Seven roles are used as a framework for ana- in taking scholarly approaches to their practice and
lysing good clinical teaching. The roles are medical demonstrating them to others.
expert, communicator, collaborator, manager, advo- Conclusion Good clinical teaching is concerned with
cate, scholar and professional. providing role models for good practice, making good
Results The analysis of clinical teaching and clinical practice visible and explaining it to trainees. This is
practice demonstrates that they are closely linked. As the very basis of clinicians as professionals, the seventh
experts, clinical teachers are involved in research, role, and should be the foundation for the further
information retrieval and sharing of knowledge or development of clinicians as excellent clinical
teaching. Good communication with trainees, patients teachers.
and colleagues de®nes teaching excellence. Clinicians Keywords Australia; clinical clerkship, *standards;
can `teach' collaboration by acting as role models and *physician's role; teaching, *standards, methods.
by encouraging learners to understand the responsibil- Medical Education 2000;34:820±826
ities of other health professionals. As managers,

medical centres'.1 There is now a recognition that the

Introduction
patient mix in teaching hospitals, with a high propor-
Clinical teaching is at the centre of medical education. tion of acute, short-stay patients is no longer repre-
Traditionally it has taken place in large teaching hos- sentative of the distribution of disease in the wider
pitals or academic medical centres. Indeed, education community. Changes in demography, ageing popula-
has been described as the `heart and soul of academic tions, patient expectations, developments in disease
treatments and information technology are signi®cantly
1
Flinders University, Adelaide, Australia altering the location of care, with recent increased
2
University of Queensland, Brisbane, Australia interest in education in ambulatory or community-
3
1 James Cook University, Townsville, Australia
4
based settings. Future professional boundaries are
CHIME, Royal Free and University College, London, UK
5
2 University of Kentucky, Lexington, KY, USA
being rede®ned in the light of these changes.
6
University of Shef®eld, UK There is increasing concern about the ability to
7
Institute of Clinical Evaluation, Philadelphia, USA maintain clinical teaching in what Iglehart describes as
8
University of Leeds, UK
9
3 University of Toronto, Ontario, Canada `the new environment of health care'.2 There have
10
Division of Endocrinology and Metabolism. Dalhousie Medical always been competing demands between teaching and
School, Canada service for clinical teachers, but this has been brought
11
University of Toronto & Hospital for Sick Children, Toronto,
Canada into sharp relief recently, for example, in government-
Correspondence: Professor David Prideaux, Professor of Medical Edu- funded hospital systems in the United Kingdom or
cation, Flinders University, GPO Box 2100, Adelaide 5001, Australia Australia. As costs are cut in public hospitals the

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Clinical teaching: maintaining an educational role for doctors · D Prideaux et al. 821

pressure for clinicians to devote more time to service scholar and professional.4 An understanding, and prep-
and less time to teaching and research mounts. In the aration for, these roles should be inculcated into all
United States, revenue for patient care has been used to levels of medical education.
subsidize medical education. The introduction of Although there are alternative models, in this paper
managed care has forced down revenue from clinical we have chosen the CanMEDS 2000 model as a
service and reduced the ability to maintain this subsidy. framework. We will discuss each of the roles in turn,
Another emerging hallmark of the new health envi- demonstrating how teaching can be incorporated
ronment is integration. Integrated care and fundamentally into the core business of clinicians, how
co-ordinated care are the bases of some key expecta- it can be adapted to the changing clinical environment
tions of health sector reforms in a number of countries. and how it need not be sacri®ced to service demands.
Integration offers a major opportunity for the If clinical teaching is to ¯ourish in the new environ-
advancement of interprofessional education. ment of health care it must be thoroughly integrated
The educational role of clinical teachers has into all aspects of medical practice. In this paper we will
expanded to include teaching in clinical skills labora- address clinical teaching at different levels. The medical
tories, the use of simulated/standardized patients, and educator is referred to as the clinical teacher. Medical
the use of computers and information technology. students, residents, and registrars are referred to as
Despite this and the changing environment of health `trainees'.
care, the necessity of providing good clinical teaching
and learning in patient-care contexts remains as strong
The clinical teacher as medical expert
as ever. The challenge is to continue to provide
`innovative' and quality teaching in a manner Amongst other things medical experts possess a: `de®ned
which `supports the teachers themselves', by utilizing body of knowledge and procedural skills which are
the strengths they used to collect and
derive from good interpret data, make
clinical practice.1 This appropriate clinical
Key learning points
may be achieved by decisions and carry out
reorganizing the struc- · An understanding of all roles the competent practitioner diagnostic and thera-
ture of teaching to must ful®l to meet future societal needs, such as those peutic procedures¼'.4
meet the realities of described in the CanMEDS 2000 project, must be incul- In many instances
the new environment. cated into all levels of medical education. These roles are: the bene®t of the
Ultimately however, medical expert, communicator, collaborator, manager, expertise residing in
it may well require health advocate, scholar and professional. the experienced clini-
new models and · Clinical teaching must adapt to the realities of clinical cian can be transmit-
approaches to clinical practice in the 21st century ± a changing clinical environ- ted effectively and ef-
teaching itself which ment and increasing demands on clinical teachers' time. ®ciently to the patient
are more appropriate · The quality of clinical teaching, and the con¯ict between only through others'
for and compatible teaching and service, can both be addressed by role work. The General
with the new clinical modelling good practice, making it visible and explaining Medical Council in the
environment. it to trainees. UK has indicated that
The Royal College all doctors have, as a
of Physicians and primary function of
Surgeons of Canada's 2000 Project on Canadian their expertise, a duty to contribute to the education
Medical Education Directions for Specialists and training of other doctors around them,5 in order,
(CanMEDS 2000) considered future societal health primarily, to ensure better patient outcomes. This
care needs and their implications for postgraduate may be construed as clinical supervision.6 However
medical education. CanMEDS 2000 has described a supervision in the clinical context has been de®ned as:
framework for generic competencies that are common `The provision of guidance and feedback on matters of
to all specialists and sets future directions for post- personal, professional and educational development
graduate medical education in Canada. It is also used in the context of the trainees' experience of providing
in another contribution to this series, as a way of safe and appropriate patient care'.6
3
conceptualizing good clinical teaching. The roles It is evident that this contains a large component
described within CanMEDS 2000 are: medical expert, of activity that could equally be classi®ed as clini-
communicator, collaborator, manager, health advocate, cal teaching; guidance, demonstration, observation,

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822 Clinical teaching: maintaining an educational role for doctors · D Prideaux et al.

feedback, correction and re¯ection. The important teachers. This is evident, for example in chart entries
and overriding feature is that such activity is essential which provide legible, concise and accurate documen-
to provide sound and competent medical care to tation without being used to record disagreements
patients. between doctors. It is also evident in standards of verbal
A key `value',7 of this expertise is that it is kept up communication where patient details are discussed
to date. This is possible only by research, or by sensitively with colleagues without use of colloquial
information retrieval, and through the sharing of terms used in the popular press or media. Thus, for the
knowledge and skills; in other words, through teach- teacher as communicator the potential con¯ict between
ing. In this case the expert may be the recipient of the teaching and service demands diminishes in impor-
teaching, i.e. the learner, but it will almost certainly be tance. Good communication with trainees, patients and
delivered by another expert. It is thus an inescapable colleagues is good teaching and good clinical practice.
contention that teaching activity is essential to good The two are largely inseparable.
medical practice.
The clinical teacher as collaborator
The clinical teacher as communicator
The practice of medicine has long been a collaborative
The clinical teacher communicates with trainees in activity involving multiprofessional teams. In the future,
various settings from the bedside to the lecture theatre effective collaboration with patients and multidisciplin-
and for various functions from teaching and assessment ary teams will be needed for provision of optimal patient
to advising and providing feedback. Trainees most care, education and research.4 The bene®ts of good
certainly recognize the importance of their teachers' teamwork to those who deliver health care, are improved
communication skills. The successful clinical teacher patient care, ®nancial savings and a better working en-
has to be a skilled communicator and must be able to vironment.14 Working as a member of a team requires:
adapt his or her communication skills to the various negotiation skills, being willing to share and accept re-
settings and contexts. Communicating expectations,8 sponsibility when making decisions, learning to under-
discussing concepts and the importance of the material stand and appreciate others' strengths and weaknesses,
to be learned9 and providing relevant feedback10 are all open-mindedness, valuing each others' opinions, indi-
considered by trainees to be signi®cant attributes of viduals being prepared to evaluate and assess their own
good teachers. The ability to communicate effectively behaviour as well as the function of the team, and rec-
with trainees de®nes teaching excellence. ognizing the contributions of different professions within
The teaching of trainees frequently occurs in the the health care team; all of which need to be learned.15
presence of patients either in one-on-one ambulatory The teaching of collaboration between different
settings or with multiple trainees and teachers in hos- members of health teams has not, until recently, been a
pital settings. Several studies indicate the link between strong part of medical education, however, learning
good communication and rapport with patients and together has been recognized as an important step on
excellence in teaching.11 Furthermore, effective patient the way to achieving this. Nonetheless, can we assume
communication may have the potential to in¯uence that by simply putting people together, effective learn-
patient outcomes by increasing patient satisfaction,12 ing will take place, or that it will produce individuals
improving medication compliance and reducing length willing to collaborate in the health care environment?
of hospitalization.13 This is a powerful illustration of Experience suggests that it will not. An ambitious
how clinical teaching can be effectively integrated into project involving medical, dental, nursing and phar-
everyday clinical practice. Teaching by positive mod- macy students amongst others, showed that in this sit-
elling of good communication actually contributes to uation the different professional groups tended to
some better patient outcomes. ignore each other, resented the presence of the other
The same argument can be applied to communica- groups and felt that their learning opportunities were
tion with other doctors as the clinical teacher frequently being diluted.16
communicates with colleagues, either verbally or in For credibility, and to satisfy the conditions of inte-
writing, in the presence of trainees. Again effective gration of service and teaching as advocated in this
communication with colleagues is not only vital to the paper, collaboration must been seen to be founded in
delivery of health care but also in shaping behaviour of reality and viewed by all participants as mutually rele-
trainees through role modelling. Good professional vant. It is counter-productive to involve groups of
written and oral communication with colleagues is professionals, who will never work in the same area
characteristic of well-respected clinicians and clinical of patient care, in training sessions merely for the sake

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Clinical teaching: maintaining an educational role for doctors · D Prideaux et al. 823

of teaching convenience. Indeed, it may reinforce In the UK the General Medical Council has
prejudices against collaborative learning. It is vital also provided a document in recognition of doctors'
to avoid the physician-centred approach to colla- contributions to the management of health services.
boration, and all health care groups must feel that they This document stipulates that all doctors have some
enter the learning sessions on equal standing. Setting responsibilities for the use of resources, that many
up collaborative learning is not easy and there may be will be working in teams and be involved in the
immense practical problems such as scheduling, ®nding supervision of colleagues. They point out that recent
appropriate venues and tutor provision to overcome. changes in the NHS, such as clinical governance will
However in the clinical setting, clinicians can `teach' make doctors' roles as managers more extensive and
collaboration by acting as role models and also by better de®ned. The General Medical Council of
encouraging learners to understand the responsibilities Great Britain suggests that all doctors have a pro-
of other health professionals and to develop respect for fessional obligation to contribute to the education
those roles. The clinical environment in which the and training of other doctors, must be prepared to
teacher works should reinforce this collaboration, for oversee and manage less experienced colleagues, and
example the use of multidisciplinary patient confer- must ensure that trainees are properly supervised.18
ences. Clinical teaching should highlight the import- This includes the ability to carry out formal
ance of each professional group's contribution to the appraisals of them.
improvement in health of the population and individual Clinical teachers need to be effective managers of
patients, and should emphasize the multiplicity of their own workloads and thereby be role models for
expertise required. trainees. There is a ®nite amount of time available for
Collaboration can help in re-orientating health clinical teaching. Teachers should demonstrate and
systems towards the patient. There is frequently a teach time management throughout all their work.
marked difference between what the professionals Clinical teachers should be role models in dealing with
describe as a positive outcome, and what the patients changing clinical environments.
perceive as a positive outcome. Individuals are Clinical teachers also need to be effective managers
becoming empowered to make personal choices and of learning resources, encouraging learners to take more
they, and their families, are demanding a more responsibilities for their learning.19 Teachers should
cohesive team approach to care. Care-managed understand the curriculum and make it explicit to the
pathways, protocols, core skills and seamless care are trainees, ensure an appropriate setting for clinical
all dependent on team work and shared ownership of teaching with appropriate patient mix, empower
care. The professions already possess a wide variety learners to make best use of the `teaching moment',
of core skills and knowledge, but without collabor- improve trainees' performance and change practice
ation and education in collaborative methods, they through feedback. In a survey of Senior House Of®cers
are frequently unable to share these effectively so in medicine in Scotland, Baldwin et al. found a lack of
that the patient bene®ts. The challenge now is to feedback, and lack of consultant's time for teaching
measure the effect collaboration has on patient adversely affected training.20
outcome from the patient perspective, and to dem- The clinical teacher as a manager needs to recognize
onstrate how the effective teaching of collaboration his/her own needs for development. The academic
can be integrated in clinical practice and, in turn, medical centre has a managerial responsibility to the
contribute to healthier patient outcomes. clinical teacher and learner by ensuring that the infra-
structure is in place to support staff development and
that the responsibility for it is clear. Other responsibil-
The clinical teacher as manager
ities of the academic centre include creating a positive
Specialists need to be able to prioritize, to work effectively environment to support teaching and learning and
as part of the health care team, to be able to utilize putting in place systematic appraisal, and feedback to,
resources, including information technology, and man- clinical teachers.
age time effectively.4 Physicians routinely function as It is clear that the clinical teacher has an increasing
managers of individual patient care but have recently number of commitments involving the care of patients,
assumed increasing managerial responsibilities within maintaining an effective research pro®le, in addition to
the health care system.17 Irrespective of their position in being a manager and a teacher. The development of
the health system, all medical practitioners from sophisticated management skills however, are likely to
internship onwards need to have effective management make our clinical teachers more ef®cient and therefore
skills. more effective.

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824 Clinical teaching: maintaining an educational role for doctors · D Prideaux et al.

during chart review, discharge planning and feedback

The clinical teacher as health advocate
on discharge. Home visits and attendance at clinics and
Advocacy, the act of pleading for, or interceding on meetings provide further opportunities for teaching
behalf of a person or persons is an attribute with par- about advocacy as do practical experiences with
ticular importance in the medical profession. During patients such as shopping trips for diabetic patients.
the reform of medical education over the past two These will often take place in an interdisciplinary con-
decades, professional competencies have been de®ned text. Finally, clinicians should use experiences arising
to include understanding the community role in health, from discussion with patients' representatives as
expanding access to care, and including patients and teaching opportunities. Rather than being locked out of
families as partners.21 Advocacy activities in the social, such discussions trainees can learn by skilful facilitation
environmental and biological arenas that determine the of learning in these events.
health of an individual patient and patients in society Many clinicians are involved in advocacy at a com-
are viewed as essential for doctors. Evans states that munity level. Again these provide good opportunities
`surely a small part of each physician's responsibility for teaching and learning. Clinicians can guide partici-
should extend beyond the care of individual patients to pation in community events, encourage involvement in
the advocacy for changes in the community's policy and community health promotion or enable trainees to
practices that in¯uence determinants of health, causes bene®t from involvement in prison medical services or
of disease and the effectiveness of health services'.22 review boards for welfare bene®ts.
Several medical schools have described their pro- Finally clinicians have advocacy roles at a population
grammes to expose students to their roles as commu- level which they can demonstrate to trainees and
nity advocates.23,24 These programmes have focused on encourage their participation. Discussion of current
experiential learning activities in the community with social issues relevant to medicine, meetings with
an emphasis on observation of social and political patients and consumer advocacy groups and participa-
determinants of health, participation in voluntary tion in professional organizations are all valuable
activities and interventions in the community with a activities from which trainees can learn the principles
view to improving the relationship between the student and practice of advocacy.
and patients. Advocacy is an essential component of health pro-
Advocacy experiences have been addressed by motion re¯ecting social, environmental and biological
authors including Lozano et al.25 who described their factors which determine the health of the individual
paediatric residency programme experience in training patient, the practice population and the community. As
residents in child advocacy. They provided illustrative Berwick26 has suggested, physicians need new skills to
examples of resident projects including educating par- become leaders in improving health care by becoming
ents on the effects of second-hand smoke, expanding more active and in¯uential citizens of their health care
child restraint law, regulating child labour in Wash- communities. The skills need to be passed on to the
ington State and reducing the use of infant walkers in next generation of physicians. Encouraging and teach-
the United States. ing advocacy to trainees is an important role for clinical
The clinical teacher's contribution in teaching and teachers as they provide daily care to their patients.
role modelling health advocacy is essential. The role is
dependent on the mix of undergraduate, postgraduate,
The clinical teacher as scholar
and continuing education learners and on the particular
specialty and the setting for teaching. The programme Of all the de®ned roles of clinicians it is that of `scholar'
and the teacher de®ne opportunities to identify and that most readily leads to a signi®cant contribution to
discuss determinants of health and the health and social clinical teaching. After all the very basis of scholarship
policy procedures related to the patient population. is founded in teaching and research. However, given
The key is to identify and teach speci®c knowledge and the increased service commitments facing clinicians, as
skills in this area, as well as to demonstrate a positive outlined earlier in this paper, it may be more appro-
approach to advocacy issues, through working colla- priate to consider whether the teaching contribution of
boratively with the interdisciplinary health care team, clinicians should be measured in terms of quality rather
with the patients, their families and their communities. than necessarily quantity, even though many clinical
Opportunities exist to teach advocacy when clinicians course co-ordinators may be inclined to disagree.
and trainees engage in clinical service, either at an There are three competencies for clinicians that
individual community or population level. At the indi- relate to teaching in the CanMEDS 2000 project. The
vidual level advocacy and its importance can be taught ®rst involves maintaining a commitment to personal

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Clinical teaching: maintaining an educational role for doctors · D Prideaux et al. 825

continuing education. By modelling and making their change in the attitude of some employers. Good
own personal educational strategies visible, clinicians educational practice has to be seen to be a valid
can provide powerful examples for their educational scholarly activity and should be subject to a reward
charges to follow. They can also assist trainees in system in the same way that other aspects of clinical
facilitating self-direction in learning through assistance practice are recognized.
with goal setting and appraising. Their goal should be The same arguments can be advanced for the schol-
to help trainees to make the most of the experiences arly roles of the clinician in research. Clinicians need to
offered to them by setting goals, relating them to the be committed to research and demonstrate such com-
curriculum and pursuing them. mitment to those associated with them. It may be very
Clinicians as scholars locate, use and appraise the dif®cult to be an active provider of clinical service and
best available evidence to inform their practice. Again teacher and researcher in contemporary health organ-
the important thing is to value, model and make this izations but clinicians can make a signi®cant contribu-
explicit for those they teach. Not only should trainees tion by the establishment of teaching and research as
be invited to existing or speci®cally planned critical core values and activities in good clinical practice.
appraisal sessions, they should be encouraged to locate,
use and critically appraise evidence in ward rounds,
Conclusion: the clinical teacher
patient presentations and throughout all of their clinical
as professional
experiences. Clinical teachers need to constantly rein-
force and apply the principles of evidence-based medi- As indicated in the introduction, this paper is con-
cine and critical appraisal that their trainees have cerned with the adaptation of clinical teaching to the
learned elsewhere. realities of clinical practice in the 21st century. It is
Finally clinicians are responsible for facilitating the recognized that clinical teachers face increasing
learning of others in their sphere of in¯uence; patients, demands on their time and so need to be employed
trainees and other health professionals. This follows on effectively. The paper, so far, has examined the
from the ®rst of the competencies listed in this section. opportunities for teaching arising from six of the seven
Clinicians need to demonstrate their own commitment roles of doctors as de®ned by the CanMEDS 2000
to education and then establish a positive educational statement. What appears to be a pervasive theme
environment for all. Further they are in a unique throughout the discussion of the six roles is that clinical
position to act as brokers for the educational roles of teaching is concerned with providing role models of
others. They can enable residents to gain educational good practice, making it visible and explaining it to
skills and experience through teaching students, and trainees. If good clinical teaching is characterized in this
enable students to gain the same through teaching way there is the potential to improve the quality of the
patients. Most importantly, clinicians can teach in a teaching and perhaps to address the con¯ict between
manner which recognizes the different educational teaching and service. Thus it would be sensible to
needs of different groups in the clinical situation, thus concentrate the efforts of senior clinical staff on these
demonstrating a fundamental educational principle to types of activities and leave the teaching of basic
those associated with them. knowledge and skills to other staff, to other methods
The main conclusion to be drawn from all of the and in other environments.
above is that clinicians are very well placed to establish The preceding discussions can be brought together
a context or climate in which education can ¯ourish. through consideration of the seventh role, the clinical
There is evidence that those being taught recognize teacher as professional: `deliver(ing) high quality care',
the ability to establish a good educational climate as demonstrating `appropriate personal and interpersonal
one of the distinguishing characteristics of effective behaviour' and practising medicine in an `ethically
teachers. Both Ullian et al.11 and Irby27 have put responsible' manner. These encompass all of the pre-
forward claims indicating that good clinical teachers vious six roles. The important thing for trainees is that
are those that act as role models, effective supervisors, their clinical teachers act professionally, are seen to act
dynamic teachers and supportive persons. The former professionally and ensure that their educational charges
is based on evidence of studies of family practice follow their good example. This ultimately is the single
residents and the latter in the literature on ambulatory most important contribution that a clinical teacher can
teaching. It is far more productive to assess clinical make as the health care environment around them
teaching in these terms than just counting numbers of changes and the nature of their work intensi®es.
tutorials given or bedside encounters conducted. In In essence, the message of this paper is simple;
order to achieve this there needs to be a climate of undertake good practice, demonstrate good practice

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826 Clinical teaching: maintaining an educational role for doctors · D Prideaux et al.

and explain good practice. This should result in good 13 Stewart M, Brown J, Boon H, Galajda J, Meredith L, Sangster
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14 The Standing Committee on Postgraduate Medical, Dental
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Education (SCOPME). Multiprofessional Working and Learn-
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ing: Sharing the Education Challenge. London: The Standing
always taking them back to basic educational principles.
Committee; 1997.
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17 Leatt P. Physicians in health care management: 1. Physicians
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