The Stanford center’s principles of clinical education have reached tens of thousands of medical teachers all over the world.
December 9, 2016 - By Kathy Zonana
Kelley Skeff and Georgette Stratos were holding a two-day faculty development seminar at UCLA in September when one of the participants spoke up: “I didn’t think this was going to be so fun,” she said.
Teaching is embedded in medicine, Skeff said, perhaps more than in any other profession. But medical faculty are often anointed teachers without any real training in the subject, and they may not realize how they can improve. So he tries to tap into their innate desires for analytical challenge and self-improvement.
“We’ve not consistently capitalized on the idea of helping teachers do something they believe in, which is figuring out how to do things more effectively,” said Skeff. “People get fed by the teaching that they do.”
Skeff, MD, PhD, a professor of medicine, and Stratos, PhD, a senior research scholar in medicine, co-direct the Stanford Faculty Development Center for Medical Teachers. The center, which marked its 30th anniversary this year, brings a half-dozen medical faculty to Stanford for a month each autumn, preparing them to lead a series of seven seminars in clinical teaching when they return to their home institutions. Skeff and Stratos also host a follow-up course in basic-science teaching, and provide shorter teaching-improvement workshops throughout the world.
“I can say without hyperbole that it changed my life,” said Bradley Sharpe, MD, a professor of medicine at UC-San Francisco, who took the clinical-teaching course in 2006. “It revolutionized the way I viewed my clinical teaching and the clinical teaching of others, mainly in having a structured, evidence-based approach to teaching, much as we do for other aspects of clinical medicine.”
Keys to effective clinical teaching
Skeff was a doctoral student at the Stanford Graduate School of Education in 1979, analyzing videotapes of medical teaching for his dissertation, when a colleague suggested he collaborate with Stratos, who was finishing her PhD in educational psychology at UC-Berkeley. “For me, meeting Georgette was such a gift,” Skeff said. “She has brought to the program such a precise and analytical mind.”
After they completed their PhDs, Skeff and Stratos worked together to develop medical education courses and seek funding to support them. Their flagship, the monthlong clinical-teaching course, grew out of Skeff’s dissertation. It provides instruction on seven facets of how to impart a good medical education to any trainee: learning climate, control of session, communication of goals, promotion of understanding and retention, evaluation, feedback and promotion of self-directed learning.
“It’s amazingly timeless,” said Sallie De Golia, MD, a clinical professor of psychiatry and behavioral sciences who teaches faculty development workshops at Stanford and nationally. “They developed it in the mid-’80s, and it’s so relevant today.”
You get more buy-in from participants when they realize it’s not about wrong or right ways to teach.
Medical teachers who have taken the course say it endures because it equips participants with widely applicable behavioral techniques, rather than a bag of content-specific teaching tricks. “It isn’t prescriptive,” said Dana Dunne, MD, associate professor of medicine at Yale. “You get more buy-in from participants when they realize it’s not about wrong or right ways to teach; it’s more about introducing a variety of teaching behaviors to increase their versatility,” so they can more effectively teach different types of learners in varying situations.
“There’s something really special about the relationship between a teacher and a student,” said Skeff, the George DeForest Barnett Professor in Medicine. “There have been a tremendous number of changes in medical education, and yet the potential power of the relationship between a teacher and a student never changes.”
“At the heart of the Stanford program is essentially a learner-centered approach,” said Louis Pangaro, MD, professor and chair of medicine at the Uniformed Services University of Health Sciences, the federal health-professions academy. “A learner-centered approach means not only that the teacher feels good about knowing their material, mastering knowledge of cardiology or whatever it is, but that their purpose is to help someone else become independent. It depends on the teacher — the person of presumed superior authority and power — orienting their work toward the learner. I’m not sure we do this as well as we should, but I think the Stanford program is a milestone in doing this.”
Participants are grateful that Skeff and Stratos provide methods of giving feedback that their students won’t dread. “I have been groomed to be kind, caring and compassionate to patients,” said Debra Litzelman, MD, professor of medicine at Indiana University. “But Kelley and Georgette absolutely reinforced in me the need to be kind, caring and compassionate to our learners. You can’t go into a room and be kind, caring and compassionate to your patient and then come out and yell at your medical students. And I still see that happening. I still see people who finish up a two-week rotation with a student and don’t know their name.”
Course participants are taught that one key to successfully implementing clinical-teaching techniques is to cultivate the attitude that everyone is there to learn and improve — faculty included. “One of my favorite things about the Stanford course is the acknowledgment that effective teachers admit the limits of what they know and of what the science is, and that engenders a sense of curiosity in other people,” said Michael Barnes, MD, associate professor of medicine at the Oakland University William Beaumont School of Medicine. In that kind of environment, he said, learners may be more motivated to admit their own limitations.
“A lot of clinical teaching is questioning,” said Lisa Coplit, MD, the associate dean for faculty development at Quinnipiac University’s Frank H. Netter MD School of Medicine. Until she took the course in 2003, however, “I never had any insight into the types of questions I was asking and why,” she said. “Now I look at questions as an unbelievably valuable tool. Being deliberate about the questions I ask, I can really zero in on one piece of a learner’s performance. So if I think this person is struggling with differential diagnoses, I need to ask them analysis/synthesis-type questions. It’s also such a great way to model for learners the types of questions they should be asking themselves. If all we’re asking are recall questions, we’re teaching them that that’s what’s important. More important is, how do you think? How do you inquire? How do you self-assess? Those are the really big questions in medicine.”
The dissemination model
Behind course participants’ dedication to improving their teaching is, ultimately, their devotion to patient care. “There is often somebody at the end of the line for whom the stakes of this type of teaching are extraordinarily important, and everyone knows that,” Stratos said.
Pangaro said, “If you believe that our role as physicians is to serve patients, then anything that enhances the humanity, the other-centeredness of a physician, is good.”
By design, course participants pass along what they have learned to other medical educators, who do the same in turn. Pangaro, for example, has trained almost 1,000 physicians in clinical-teaching techniques.
If we become humanistic, respectful teachers, hopefully the next generation will too.
More than 200 faculty members, hailing from more than half of U.S. medical schools and several international institutions, have completed the Faculty Development Center’s clinical-teaching course. Stratos estimates the curriculum has been taught to 10,000-15,000 medical educators, and Skeff quickly revises that estimate upward to 25,000. Both of them know they’re underestimating.
In addition to disseminating their educational precepts worldwide, each year Skeff and Stratos instruct 200 Stanford School of Medicine teaching assistants, postdoctoral scholars, fellows, residents and faculty, often in collaboration with colleagues who have taken the clinical-teaching course. “It makes our faculty better teachers so we can provide better medical education to our learners,” said associate professor of medicine Lars Osterberg, MD, who directs Educators-4-CARE, a mentoring program designed to foster the development of Stanford medical students as skilled and compassionate physicians. “Kelley and Georgette’s thinking about an organized way of teaching has helped our faculty provide peer feedback.”
In class, Skeff and Stratos deliberately model the methods they teach, as do their students when teaching others. “If you’re pursuing an approach to education and modeling it, the hope is that that also educates the future physician in modeling to the next generation,” said De Golia. “If we become humanistic, respectful teachers, hopefully the next generation will too.”
Skeff and Stratos “have ‘kids’ all around the world, who look to them as mentors for the rest of their life,” said Barnes. Several have made careers out of faculty development. “Everyone talks about medical students having that aha moment,” said Coplit. “I do get great joy from that, but I also have great joy when I get to witness a colleague have an aha moment about their teaching.”
“I’m never going to publish an article in a peer-reviewed journal that revolutionizes and changes patient care,” said Sharpe. “But clinical teaching is a way you can have the same exponential impact. If I work with 20 interns, and in each encounter with a patient there’s a way they say a word or a way they examine the heart, I’ve now touched as many as 100,000 patients in my teaching. If five of them teach their interns the same thing, then there are 500,000 I’ve touched in some small way.”
“I talk about this as the merging of two noble professions,” said Skeff. “The noble profession of medicine and the noble profession of education become synergistic in their societal impacts. The synergy then has an impact on every physician whom that teacher touches, and then every patient whom that physician touches. It’s an exponential impact. That’s why medical teachers teach.”
About Stanford Medicine
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