| Abstract|| |
This study aims at identifying characteristics and behavioral patterns associated with the ideal tutor in different medical fields. This study is expected to answer two questions, first is effective supervision and how can this be determined? And secondly, what skills and qualities do effective supervisors need? An English limited search was performed in many databases including MEDLINE, BEI, and International ERIC for the last 20 years using many search items to identify characteristics cited in the literature as being important for effective clinical teaching. One hundred thirty two articles identified the review excluded literature relating to research supervision. Findings revealed that some of these investigations relied on the tutor's point of view, others on a resident's or a student's opinion or both. Descriptors for effective clinical teachers were categorized into three main classes: (a) teaching skills (i.e. well-prepared, practices evidence-based medicine and believes in its principles and applications, effective, accessible, and provides and accepts both positive and negative feedback), (b) personality (i.e. enthusiastic, respectable, sincere, confident, humanitarian, and compassionate), and (c) attitude (i.e. health advocate, good role-model, encouraging, non-judgmental, aware of learners' growth, well-groomed, and appropriately dressed). Other factors such as the trainer's health (i.e. professional, personal, and spiritual fulfillment) and his/her scholarly activities were also identified.
|How to cite this article:|
Alsultan M. What makes an effective clinical trainer?. Saudi J Kidney Dis Transpl 2011;22:1229-35
| Introduction|| |
To achieve effective clinical training and excel at post-graduate education, identifying the characteristics that make an excellent clinical tutor is the key element, which determines the quality of training received by residents targeted by a given training program. Naturally, attemptting to pinpoint those qualities based only on hypotheses can be a difficult task. It gets even more difficult to rank the identified qualities based on its importance and in relation to different clinical fields.
In an attempt to define the characteristics associated with excellent clinical tutors and trainers, we conducted a literature review on this topic. In addition, we devised to a questionnaire [Table 1], [Table 2] that allowed Saudi medical residents from different training programs of different specialties to rank those characteristics by importance.
|Table 2: Questionnaire devised to explore the residents and faculty opinion.|
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Definition: Supervision is a complex activity that includes all domains of education (knowledge, psychomotor, and attitude). Bridget proctor  outlined three functions of supervision which are: (a) normative (administrative), (b) formative (educational), and (c) restorative (supportive). Notably, those functions are considered the most influential formulation of the functions of supervision in the literature. We used the Kilminster's definition of supervision for medicine: the provision of monitoring, guidance, and feedback on matters of personal, professional, and educational development in the context of the doctor's care of patients. This would include the ability to anticipate doctor's strengths and weaknesses in particular clinical situations in order to maximize the patients' safety. 
| Methodology|| |
A limited search was performed in many English databases including MEDLINE, BEI, and International ERIC for the last 20 years using many search items to identify the characteristics cited in the literature as being important for effective clinical teaching. We found 132 articles excluding literature related to research supervision [Table 1].
Review the literature: The approach we applied was to evaluate the literature and extract elements that could help in answering the following questions:
Identifying the characteristics was determined by reviewing the literature, answering the above questions, collecting professionals' perceptions from many fields of medicine and education, seeking residents' opinion, and post adhoc analysis. From the characteristics identified in the literature as being potentially important, a list of 20 attributes of effective clinical teachers were compiled. This list was reviewed and agreed upon subsequent to several brainstorming sessions involving both faculty and residents from different residency training programs.
- Is supervision effective and how can this be determined?
- What skills and qualities do effective supervisors need?
| Results and Discussion|| |
There have been many reports since the seventies describing the important characteristics and behavioral patterns associated with the ideal tutor in different medical fields. Some of these investigations relied on the tutor's point of view and others on a resident's or a student's opinion or both. There were also studies that examined the impact of the different characteristics (e.g. being a good role model) on the overall definition of an excellent clinical tutor.
A nursing education study emphasized focusing on trainees as a part of the educator's role to produce competent practitioners.  In the field of Medicine, Irby put forward what could be considered the first attempt at classifying the components of teacher's effectiveness into specific factors and he tried to validate these factors.  He found that the best characteristics of clinical teacher based on the highest factor ratings included enthusiasm, clarity, good organization, and clinical competence. The major difference between the best and the worst clinical teachers was the instructional skills of the best (organization, clarity of presentation, enthusiasm, and interaction skills) and the personal attributes of the worst (arrogance, lack of confidence, dogmatism, and insensitivity). No significant differences were found in the teachers ratings based on department, teaching method, or professional role. 
Irby published another study but in ambulatory care settings.  He underscored the importance of respecting the autonomy of the learner and he concluded that there was no difference regarding the needed characteristics of clinical teachers whether in ambulatory care settings or forward teaching. 
Irby summarized in his thematic review the characteristics of effective clinical tutor in an ambulatory care setting. He described the results of those studies in relation to the work by Ullian et al who identified four roles of effective clinical teachers that defined the clinical teacher as a model physician, an effective supervisor, a dynamic teacher, and a supportive person. 
The six domains of knowledge essential for teaching excellence in the context of teaching rounds comprise clinical knowledge of medicine and patients, context of practice, general principles of teaching and case-based teaching scripts. They were combined and discussed in relation to previous researches. 
Another literature review on "What makes a good clinical teacher in Medicine?" by Sutkin and colleagues  collectively analyzed 68 articles pertinent to their question. Based on those articles, the authors identified 480 descriptors and grouped them into 49 themes, which were clustered into three main categories: physician, teacher, and human characteristics. They presented the most commonly reported themes with the number of citations as the following: medical/clinical knowledge (30 citations), clinical and technical skills/competence, clinical reasoning (28 citations), positive relationships with students and supportive learning environment (27 citations), communication skills (21 citations), and enthusiasm. 
Another case control study was conducted among two groups of attending physicians in four different teaching hospitals in the departments of Internal Medicine.  The objective was to identify the attributes that distinguish physicians who serve as excellent role models. A strong association was found between conducting greater assigned teaching responsibilities and representing an excellent role model.
Strong clinical skills were found to be important, but not sufficient for being an excellent role model. The perceived barriers for playing a good role model include: being impatient and overly opinionated, quiet, overextended, and having difficulty in remembering names and faces. Role modeling consciousness-"specifically thinking about being role models when interacting with learners"-was also identified positively by participants in Internal Medicine departments. 
As demonstrated by Hilliard, pediatric residents and staff ranked the six out of the 15 most important qualities as follows: allowing approaches to basic concepts and problems and not only stating facts, delivering ideas and knowledge, leading discussions in a clear organized manner, having an excellent and complete clinical approach in dealing with medical problems, promoting self-directed learning and stimulating intellectual curiosity, being enthusiastic in teaching and enjoying interaction with residents, and being an excellent role model in dealing with patients and families. Notably, other characteristics such as being an outstanding researcher with excellent curriculum vitae, excellent knowledge of recent literature, and a reputation of being successful in career were not considered important to facilitate learning. Staff highly ranked two qualities: (a) enthusiasm and ability to stimulate intellectual curiosity and, (b) self-directed learning as more important than the residents besides being an excellent role model. 
In the field of Emergency Medicine, a recent study by Bandiera et al  showed partially different ranking of attributes as compared to the previous studies. They categorized characteristics into eight themes (attitude, environment, enthusiasm and motivation, receptive to student, role model, skills, confidence, and knowledge base).
Competent general practitioner trainers' traits, knowledge, and skills were examined by Boendermaker et al.  They conducted a focus group meeting, which resulted in an agreement on sorting the identified characteristics into four categories as follows:
Buchel and Edwards described a very strong agreement between family medicine residents' and faculty's opinions, as well as differences regarding effective clinical teaching attributes. Both residents and faculty agreed on the importance of clinical competence and enthusiasm and the relative unimportance of scholarly activity in defining an effective clinical educator. There were, however, significant levels of disagreement on the importance of respecting the autonomy and independence of trainees as clinicians; the residents felt it was important, while the faculty members felt the contrary. Furthermore, the residents, unlike the faculty, valued the importance of good quality educators for provision of a safe, non-judgmental, and non-threatening learning environment  in addition to the interaction with their faculty.  On the subject of being nonjudgmental, it is worth mentioning the published experience of a graduate resident, Robert Patterson. Patterson mainly recalled his residency training experience as a negative one when he was asked to write about it, probably due to judgments made by his attending physican. 
- Teaching knowledge: "knowledge about teaching methods (how and when to use them)".
- Teaching skills: "using teaching knowledge, giving feedback, being able to observe, analyze, teach the trainee to carry responsibility, encourage reflection, structure, teach (professional) skills, handle conflict, communicate (including listening), and phase training".
- Teaching attitude: "to give trainees freedom and respect, accepts criticism, show interest in the trainees, separate private life and teaching and the different roles in the teaching-relationship (teacher, colleague), prove as a role model, offer a safe environment, individualize training, be alert, be critical of trainees and their learning process, open to extra training to become a better teacher, enjoy the role of teacher, be available and reachable, create time for teaching, see things in perspective, be stimulating, not to exploit from the trainee, be loyal to the department and willing to share patients with the trainee, allow feedback, and learn from trainees".
- Personality traits: "enthusiasm, flexibility, self-knowledge, ability to reflect, self-insight, patience, integrity, and enjoying their role as a practitioner".
The type of program, community-based or academic medical center-based, significantly affected the perception of the importance of traits. Faculty and residents at academic medical centers placed more importance on teachers being well-organized role models, while community-based programs valued more enthusiastic and nonjudgmental faculty.  There were also some gender differences, as women valued autonomy of residents more than men. It's also worth noting that second year residents valued autonomy more than the first and third year residents. Predictably, faculty who were since 10-15 years in their practices placed less importance on "availability". However, the more experienced faculty (>15 years in practice) again valued "availability" since it offered some reassurance. 
Cox and Swanson attempted to identify surgical teaching behaviors that define teaching excellence. They used a constructed instrument to measure operating room teaching behaviors in a resident-based assessment system. They found that the two teaching behaviors that differentiated between superior and mediocre teaching in the operating room included demonstration of awareness and sensitivity to residents' learning needs and provision of direct and ongoing feedback regarding their progress. For clinical teaching behaviors, the two best discriminating items included positive reinforcement of the residents and provision of direct and ongoing feedback regarding their progress". Three commonly positive themes linked to residents' identification of superior teaching performance were constructed from the residents' written comments. They included demonstration of surgical technical expertise and up-to-date knowledge, allowance and encouragement of residents to participate in patients' procedures, and maintenance of learning climate of respect and support. 
Stritter et al studied the criteria of effective clinical teachers from medical students' point of view and they identified six dimensions or factors for effective clinical teaching. Preceptors' concentration on the problem solving process (giving every student a chance to discuss practical application of his knowledge and skills, giving opportunity to practice approaches and mainly being concerned with clinical judgment rather than recalling facts.  Moreover, this factor correlates well with what was described in some studies about the importance of training of students to use the explanations and guide them through the process of discovery. 
Haghdoost and Shakibi explored the characteristics of good clinical lecturers as perceived by medical students and compared them to the perception by academic staff such as being punctual, knowledgeable, ethical, patient, compassionate, honest, skillful in team work, respectful, professional, capable manager, idealist, pragmatic, and energetic. Two extra characteristics were included in staff questionnaires, being a helpful friend and a valuable colleague. The characteristics were divided into two groups; the first group contained those characteristics related to the lecturer's activity, while the second group contained characteristics that were related to personality or teaching performance of the lecturer. Based on students' perception, predictors of lecturers as "role models" consisted mostly of characteristics from the first group. Based on faculty's perception, predictors consisted of characteristics from both the groups.  It is worth mentioning that the observed diversity in many reports of opinions between the faculty and students on some of those characteristics as indicators of good residency education renders the assessment of quality programs, a difficult task. 
A review published in 2001 by Kilminster and Jolly covered the appropriate literature pertaining to all health care professions. They described the characteristics of effective clinical supervisors as they are relevant to their skills. Good or effective clinical teachers had knowledge of medicine and patients (which confers clinical credibility), exhibited general principles of teaching (including feedback and evaluation), and used case-based teaching scripts. Good clinical teachers are also known to be well organized, encourage communication with their students, appear to enjoy teaching, show a positive role model, facilitate learning tools and make them available. They asserted that factors of good teaching including the teachers' interpersonal behaviors, planning and preparation, and their ability to run a session well. Behaviors such as regard, empathy, and congruence significantly correlated with the residents' ratings of the learning values of the rotation. When supervisors behaved more as colleagues in residency programs, residents considered themselves as being self-directed. 
Due to its significant impact on clinical training, this review aims to identify the characteristics of excellent clinical tutors as perceived by both trainers and trainees. Findings revealed descriptors which were categorized into three main classes: (a) teaching skills (i.e. well-prepared, practices Evidence-Based Medicine and believes in its principles and application, effecttive, accessible, provides and accepts both positive and negative feedback), (b) personality (i.e. enthusiastic, respectable, sincere, confident, humanitarian and compassionate), and (c) attitude (i.e. health advocate, good role-model, encouraging, non-judgmental, aware of learners' growth, well-groomed, and appropriately dressed). Other factors such as the trainer's health (i.e. professsional, personal, and spiritual fulfillment) and his/her scholarly activities were also identified.
| References|| |
|1.||Supervison PB. A co-operative exercise in accountability. In: Marken M, Payne M. eds. Enabling and ensuring supervision in practice. leicester: National Youth Bureau and Council for Education and Training in Youth and Community Work; 1987. |
|2.||Kilminster SM, Jolly BC. Effective supervision in clinical practice settings: A literature review. Med Educ 2000;34:827-40. |
|3.||Griscti O, Jacono B, Jacono J. The Nurse Educator's clinical role. J Adv Nurs 2005;50(1):84-92. |
|4.||Irby DM. Clinical teacher effectiveness in medicine. J Med Educ 1978;53:808-15. |
|5.||Irby DM, Ramsey PG, Gillmore GM, et al. Characteristics of effective clinical teachers of ambulatory care medicine. Acad Med 1991;66:54-5. |
|6.||Irby DM. Teaching and learning in ambulatory care settings: A thematic review of the literature. Acad Med 1995;70:898-931. |
|7.||Irby DM. What clinical teachers in medicine need to know? Acad Med 1994;69:333-42. |
|8.||Sutkin G, Wagner E, Harris I, Schiffer R. What makes a good clinical teacher in medicine? A review of the literature. Acad Med 2008;83(5): 452-66. |
|9.||Wright SM, Kern DE, Koloder K, et al. Attributes of excellent attending-physician role models. N Engl J Med 1998;339(27):1986-93. |
|10.||Wright SM, Carrese JA. Excellence in role modelling: Insight and perspective from the pros. CMAJ 2002;167(6):638-43. |
|11.||Hillard RI. The Good and effective teacher as perceived by pediatric residents and by faculty. Am J Dis Child1990;144:1106-10. |
|12.||Bandiera G, Lee S, Tiberius R. Creating effecttive learning in today's emergency departments: How accomplished teachers get it done. Ann Emerg Med 2005;45(3):253-61. |
|13.||Boendermarker BM, Schuling J, Meyboom-de Jong B, et al. What are the characteristics of the competent general practitioner trainer? Fam Pract 2000;17:547-53. |
|14.||Buchel TL, Edwards FD. Characteristics of effective clinical teachers. Fam Med 2005;37 (1):30-5. |
|15.||Stack SJ, Watson MJ. Enriching the resident-faculty relationship. Ann Emerg Med 2001;38: 336-8. |
|16.||Patterson R. "You're the Worst Goddmn Resident I've ever had". CMAJ 1998;159:823-5. |
|17.||Cox SS, Swanson MS. Identification of teaching excellence in operating room and clinic settings. Am J Surg 2002;183:251-5. |
|18.||Stritter FT, Hain JD, Grimes DA. Clinical teaching reexamined. J Med Educ 1975;50:876-82. |
|19.||Donelan S. Explanation as a teaching technique. Wilderness Environ Med 2004;14(3):194-6. |
|20.||Haghdoost AA, Shakibi MR. Medical students and academic staff perceptions of role models: An analytical cross-sectional study. BMC Med Educ 2006;6:9. |
|21.||Klessig JM, Wolfsthal SD, Levine MA, et al. A pilot survey study to define quality in residency education. Acad Med 2000;75(1):71-3. |
Consultant - Emergency Medicine and ICU, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, P.O. Box 22490, Riyadh
[Table 1], [Table 2]