Medico1 Education 1990, 24, 518-527
An inventory to improve clinical teaching in the general internal medicine clinic M. G. A’B. HEWSON & N . M. JENSEN Department of Medicine, University of Wisconsin, Madison
Summary. The increasing occurrence of outpatient medical care has led to the need for more and better medical education in the clinic. The Wisconsin Inventory of Clinic Teaching (WICT) was developed to improve the teaching of attending doctors in a general internal medicine clinic. The items on the inventory were derived from interviews with residents and attending doctors. The inventory was shown to have validity, and to be reliable with internal consistency correlations. We found an interesting disparity between attending doctors’ and residents’ expectations concerning clinical teaching. The instrument is in use as part of a teaching improvement programme for attending doctors in a general internal medicine clinic.
doctors to see as many patients as possible), and logistical problems (the scheduling of patients in this time and space is complex). Under these circumstances, it is often difficult to coordinate good teaching with good patient care. In order to be improved, however, clinical teaching must be understood. Adams etal. (1964) used naturalistic research methods to study teaching in a clinical ward clerkship, analysing and then summarizing the descriptive data in terms of teaching behaviours. These profiles were used to generate an instrument to assess teachers’ behaviours. The instruments of Irby (1977) and Skeff (1981) both assess teaching on the wards and are significant developments in this area. An assessment instrument is needed, however, to deal with teaching in the clinic (Weinreb et al. 1981). Teaching in this setting is relatively undescribed and it is thus particularly important to develop an inventory of teaching behaviours grounded in descriptive data that are situationspecific and contextually sound (Strauss 1987). Such an instrument developed would thus be induced from detailed description rather than deduced from an educational theory or model. The approach taken to developing our instrument parallels that of Adams et al. (1964), but differs in that we developed our instrument specifically for the clinic setting.
Key words: teaching/*methods; *clinical competence; internal medicine/*educ; internship; Wisconsin
Introduction Changing hospital practices mean that more people receive their medical care as out-patients. It has thus become increasingly important for clinics to provide residency and clerkship training sites (Perkoff 1986; Foreman 1986; McPhee et al. 1987; Wones et al. 1987; Lawrence 1988). The clinic, however, presents many constraints on teaching. These include time constraints (patients are usually unwilling to spend a long time in the clinic), financial constraints (clinics are self-supporting and it is necessary for
Methods and results We developed this instrument in three phases: the development of the inventory ofteaching behaviours; the tests of validity and reliability; and the use of the instrument in a teaching improvement programme.
Correspondence: Mariana Hewson PhD, Clinical Sciences Center, 600 Highland Avenue, Madison, Wisconsin 53792, USA.
518
An inventory to improve clinical teaching Development of inventory
of clinical teaching
This phase involved collecting descriptive data from attending doctors and residents, and using these data to generate an inventory ofappropriate teaching behaviours. ( 1 ) Attending doctors’descriptions of teaching in the clinic. We initially conducted semi-structured interviews with 11 attending doctors at the University of Wisconsin, Department of Medicine, Section of General Internal Medicine about their teaching behaviours and their rationales for those behaviours. The participants included nine of the ten full-time academic staff members, one of the two part-time academic staff members and one fellow. The questions concerned four ‘staffing phases’ of attending doctors: behaviour in the conference room when reviewing the resident’s case analysis (history and physical examination, laboratory data, diagnosis and management plans); behaviour in the examination room with both the resident and patient; method of concluding with patient; and approach to supervising the completion of medical records. In addition, w e questioned the attending doctors about their opinions regarding the characteristics of, and constraints on, good teaching in the clinic. The interviews were recorded on audiotape and transcribed. We then analysed the data (transcripts) using qualitative, descriptive methods (Lincoln & Guba 1985; Strauss 1987). First, we analysed the transcripts for clear, coherent conceptions (single units of meaning). We then coded and categorized the conceptions. This method of data analysis resembles content analysis, but differs in several important ways: there is no attempt to formulate a rule, and the categories are produced inductively, not deductively, as there is no need for a priori guiding theory. In addition, the findings are specific to a given population and are not necessarily generalizable to other groups. These identified conceptions of teaching were thus self-reported attending doctor teaching behaviours.
(2) Residents’ description of teaching in the clinic. We interviewed all residents (a total of 28) in the clinic in small groups. We used semi-structured interviews to solicit residents’ ideas about which teaching behaviours of attending doctors they considered to be useful for learning. We also
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asked about the characteristics of attending doctors w h o were good teachers, and the different types of instruction received. Audiotapes o f these group interviews were also transcribed and analysed as described above. The identified conceptions were put into the form of prescriptions for behaviour, such as ‘a good attending doctor should maintain the resident’s status in the presence of the patient in the examination room.’ Each resident received an abstracted list of appropriate teaching behaviours, and their agreement or disagreement with each item was checked. The list was then modified (for example, items with less than 50% agreement were removed). (3) Development of the inventory ofclinic teaching. We used the descriptive data of appropriate teaching behaviours from the perspectives of both the residents and attending doctors to generate an inventory of clinical teaching behaviours. This involved combining the two lists, removing redundant items, and differentiating the conflated items. The result was a list (inventory) of behaviours which both attending doctors and residents believed to be appropriate for teaching in the clinic. We eventually classified the items of the inventory in terms of six roles that appear to describe the staffing function of attending doctors in the clinic. This classification is similar to one suggested by Irby (1986). The six roles are: (a) clinical role model: the attending doctor displays attitudes, clinical knowledge and skills to the resident; (b) professional mentor: the attending doctor serves as a trusted counsellor to the resident; (c) clinical supervisor: the attending doctor aims to optimize patient care in the clinic; (d) instructor: the instructional methods are appropriate to the clinic; (e) evaluator: the attending doctor seeks feedback from and gives feedback to the resident. (Qconsultant: the attending doctor contributes experience and knowledge in patient care.
The inductive process used in the descriptive phase of this study is illustrated in Table 1. The verbatim descriptions of appropriate teaching behaviours by both attending doctors and residents serve as exemplars of a category of behaviour. Each exemplar is juxtaposed with the
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Table 1. Selected verbatim comments of attending doctors (AD) and residents (R) obtained from preliminary descriptive study, with final item on WICT
Attending doctor (D)
Resident (R)
(1)
‘I think the residents can learn style from us, so I try sometimes to interact with the patient so that they (residents) will pick up on m y style because it’s different than some of the other doctors.’ RF.5
‘1 cannot think of a single attending who, if they feel strongly about something would not go back and show us the right w a y . . . and at those opportunities it is role modelling.’ R10
(1.1) Demonstrates how to manage a range of problems in the clinic.
(2)
‘I think (my approach) depends on whether they are PGl, 2 or 3s. With PGls 1 am more prone to imposing my way of doing things on them . . . I caught myself doing that with one of the PG3s the other day and by the way they were looking at me it seemed that they thought it was inappropriate. And I thought “Yeah, it probably is” and I should probably let them go on to tell me how they would approach it. So I think I’m more directive with PGls and less so with PG3s.’ LP.3
‘One important characteristic . . . is an attending who is willing to give you a fair amount of responsibility with the patient. . . I think, depending on how you have worked with them . . . (the AD) will realize if you need more supervision or not, and give a little more leeway to Rs who indicate (readiness). T8
(3.7) Adjusts amount of supervision to level of competence of residents.
(3)
‘As the Rs are presenting the problem obviously diagnostic considerations are going through my mind. . . so the questions I ask the residents are questions that 1 think would be helpful in better defining whatever is going on with the patient.’ LF.3
‘I think that we have a collegial type of relationship when we work through the patient together.’ R9
(4.3) Asks open-ended questions to explore ideas with residents (collegial teaching).
‘I think one of the nice things on this team is that attendings respect our opinions and they listen to what we say. If we have ideas of our own they don’t come out and say “No”, but they kind of guide you to possibly thinking that you came up with the ideas yourself.’ R5
(4.4)
(4) ‘If it’s an upper respiratory infection then he’ll say “In the throat I found such and such. I think we should get a culture and wait,” and then, you know, I’ll say “Well, do you think we should treat now?”, and then he’d say “I think we ought to treat now.” And then I’ll say “Well, did you check the heart for a murmur?” ’ RF.2
Questionnaire item
Questions resident to encourage thinking in different directions, when attending knows the answers.
An inventory to improve clinical teaching
52 1
Table 1 continued.
(5) ‘I have the residents pretty much present the case to me in as much detail as they desire, and then if there seem to be things missing, things I want to know, I ask them, “Do you know this”, “Do you know that?”, and either they do know i t and just didn’t mention it or they don’t know it, and we need to further investigate that. And then the next step is to ask them what they think is going on, trying to get a diagnosis from them. ’ JH. 1
‘Sometimes wejust say “We have such and such a disease and we are going to treat it like this.’’ And they will say ‘Why are you giving that test versus this test?” ’ R5
final item on the inventory, illustrating the way in which verbatim descriptions led to inventory items. The current version of the Wisconsin Inventory of Clinic Teaching (WICT) is presented in Table 2 in a condensed format. Measures of validity, reliability and generalizability
Measures were taken to establish validity, reliability and generalizability of the WICT. In the course of collecting validity data, we also observed differences between residents and attending doctors. (1) Validity of the inventory. An important component of qualitative analysis is to validate the derived categories of behaviour with the original subjects in the study (Lincoln & Guba 1985). To do this, we asked the teachers and residents to rate the importance of each item using a 3-point scale: important (3 points); neutral (2 points); and unimportant (1 point). Nine (all) of the participating full-time teachers and eight (of the 28) residents complied with this request. We calculated the mean ratings for each item for the group as a whole and also separately for the attending doctors and residents. The data showed 58 of the 62 items (93.5%) had mean ratings of more than 2.5. (We considered mean ratings between 2.5 and 3.0 to be important.) Three items (4.8%) had a mean rating between 2.25 and 2.19. We considered these to be margin-
(5.1) Questions residents to probe their knowledge and judgement.
ally important. One item (1.6%) had a rating between 2.0 and 2.49; we decided that this item was not sufficiently important to keep in the inventory. We combined and rephrased items to minimize redundancy, thus reducing the number of items to 46. The highest and lowest ranked items in terms of perceived importance by both the doctors and residents are listed in Table 3. The WICT has high face validity for both attending doctors and residents in the Department of Medicine, Section of General Internal Medicine at the University of Wisconsin, Madison. This is attributable to the inductive approach and verification of the inventory items with the participants in the study. The instrument satisfies all users concerning the appropriate teaching behaviours of attending doctors in the clinic. It does not deal with interactions that occur in class-rooms, personal offices or wards, since these were not the foci of our enquiry. (2) Reliability of the inventory. We established the reliability ofthe inventory by using a measure of internal consistency with inter-item correlations (Cronbach’s a) for the instrument as a whole and for the six roles (subcategories) described earlier. O u r hypothesis was that the instrument measures teaching in the clinic. T o do the inter-item correlation, we calculated the mean rating given to each participating attending doctor for each of the 43 inventory items. The results show particularly high a scores for the
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Table 2. The Wisconsin Inventory of Clinic Teaching (WICT) For each of the following criteria, indicate how well you think your attending doctor’s (or your own) behaviour rates, using the scale: O= unable to judge unacceptable. clearly in need of help I = barely adequate, room for much improvement 2= 3= average, typical of a good attending doctor done very well, better than most 4= 5= outstanding, nearly perfect
1.10 1.11
The attending doctor as a clinical role model Demonstrates how to manage a range of problems in the clinic. Demonstrates good patient interviewing skills. Demonstrates humanistic attitudes in relating to patients (integrity, compassion and respect). Displays technical skills pertaining to ambulatory primary care. Displays knowledge about and use of current literature pertaining to patient problems. Displays knowledge about availability and role of the spectrum of health services (PT, OT, RT, Social Work, Home Health Services, Employee Health, Nursing Homes, etc.). Displays willingness and ability to work as a team with other health professionals. Displays knowledge that is grounded in clinical experience. Displays knowledge of psychosocial aspects of medicine. Shows commitment to continued personal learning and development. Recognizes personal limitations and errors.
2.0 2.1 2.2 2.3 2.4 2.5 2.6
The aftending doctor as a professional mentor Is available for additional teaching when requested by residents. Shows sensitivity to resident’s feelings. Is available, approachable and receptive to residents’ personal problems. Inspires confidence in resident to solve clinical problems. Is enthusiastic about challenges of practice. Coaches residents in affective (emotional) aspects of medical practice.
3.0 3.1 3.2 3.3 3.4
The attending doctor (12 a clinical supervisor Promotes a cost-oriented approach to clinical problems. Uses consultants in subspecialties judiciously. Promotes good patient education by resident. Promotes keeping of medical records in a way that is thorough, legible, efficient and organized. Promotes continuity of care. Checks the validity of the resident’s history and physical findings directly with the patient. Adjusts amount of supervision to level of competence of residents. Communicates effectively the attending doctor’s expectations of residents . Reviews the adequacy of the patient management plan with resident. Demonstrates responsible time management when staffing residents.
1.0 1.1 1.2 1.3 1.4 1.5 1.6
1.7 1.8 1.9
3.5 3.6 3.7 3.8 3.9 3.10 4.0 4.1 4.2 4.3
T h e attending doctor as instructor Demonstrates enthusiasm for teaching in clinic. Engages in didactic teaching when resident’s responses indicate a need. Asks open-ended questions to explore ideas with residents (collegial teaching).
Rating
1 1 1 1 1 1
I 1 1 1 1
1 1 1 1 1 1 1 I 1 I
I I I 1 I I
I I 1
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523
Table 2 continued. 4.4 4.5 4.6 4.7 4.8 4.9 4.10 4.11 5.0 5.1 5.2
5.3 5.4 5.5
6.0 6.1 6.2 6.3
Questions resident to encourage thinking in different directions. Encourages residents to participate actively in diagnosis and management plan. Clearly and logically explains underlying basis for hidher opinions and advice. Identifies and emphasizes important elements in case analysis. Adjusts instructional approach to different levels of resident training. Demonstrates a flexible, open-minded approach to alternative suggestions by residents. Promotes reflection on clinical practice. Uses relevant scientific literature o r authoritative sources in supporting hidher clinical advice.
I
1
[ [
I I
The attending doctor as evaluator Questions residents to probe their knowledge and judgements. Asks residents to justify statements if perceived as wrong by attending doctor. Provides constructive criticism for inappropriate behaviours. Gives positive feedback for appropriate behaviours. Gives timely feedback to residents.
The attending doctor as consultmi Is available for consultation when requested by resident. Gives expert advice when resident is uncomfortable with a case. Maintains the resident’s status in presence of the patient, i.e. does not unnecessarily take over the case.
whole instrument. This gives us confidence that we are measuring appropriate teaching behaviours. In addition, the high scores for the six roles suggest that they are coherent entities. This result suggests further investigation concerning the roles o f the attending doctor in staffing residents. The inter-item correlations are presented in Table 4. (c) Generalizability of the inventory. At this point, the instrument represents clinic teaching in the Section o f General Internal Medicine at the University of Wisconsin, Madison, and may not be generalizable to other sites. It was, however, compared to the assessment instruments for teaching on in-patient wards developed by Skeff (1981) and Irby (1977), both ofwhich have made claims for reliability and validity. We found that 80% and 85% of the items in the respective instruments also occur in the WICT. This reinforces our claims of content validity, and suggests that the instrument may be generalizable to other settings. The major finding of the comparison to the
Irby and Skeff instruments was that the WICT has additional items that reflect medical practice in the clinic. These include practising in a team with allied health professionals, knowledge of psychosocial aspects of medicine, promoting patient education, and continuity of care. The WICT includes some additional instructional items (such as collegial teaching and reflective teaching) and evaluation items (such as requiring residents to justify statements). Some of these additional items reflect previously published characteristics of teaching in the clinic (Perkoff 1986; McPhee 1987). (4) Data f r o m validity studies. We observed an interesting disparity in the responses ofattending doctors and residents to some of the WICT items. As a result w e calculated xz o n the rating frequencies for each item, for the two groups. These were 2 x 2 tables since none of the items was rated as unimportant. Comparisons shown to be significantly different are listed in Table 5. These differences suggest that residents consider some instructional items to be more important
524
M . G. A’B. Hewson G N.M.]enson
than the attending doctors do. For example, residents value the following instructional behaviours more than attending doctors do: ‘demonstrates ability to organize and express ideas clearly’; ‘identifies and summarizes important elements. in a case’; ‘acknowledges and responds to residents’ questions’; ‘stimulates interest during case discussions’; ‘questions residents to encourage thinking in different directions’ and ‘to elicit their knowledge’. T h e item rated most differently concerned the settling of disagreements between the residents and attending doctors. O n the other hand, attending doctors showed a significantly higher rating o n one item: ‘manages a “generalist” range of out-patient problems’. It thus appears that residents have high expectations of attending doctors as instructors, which does not appear to be shared by the attending doctors. These results conflict with those of
Stritter et al. (1983), who suggested concordance between teacher and house staff views o n teaching in ambulatory medicine. This disparity dexrves further investigation.
Use ofthe WICT in a teaching improvement programme Along with reviews of videotapes of teaching interactions in the clinic, the W I C T is used in a teaching improvement programme. This process is similar t o the intensive feedback method of Skeff (1981). Attending doctors assess their own peformance using the WICT, and are assessed by their regular residents. The clinical teaching specialist analyses the W I C T data and presents a written report t o each attending doctor. This report provides a focus for the video review session. Attending doctors take part in the teaching improvement programme at least once
Table 3. Appropriate teaching behaviours suggested by both attending doctors and residents in rank order Rank
Item
Mean rating
1
Demonstrates how to manage a range of problems in the clinic
3.00
2
Ability to maintain a positive relationship with resident independent of resident’s level of knowledge and skill
2.96
3
Demonstrated humanistic attitudes in relating to patients Demonstrates concern for patient’s feelings
2.94 2.94
5
Competent in analysing patient’s problems Able to identify the central issues of a case
2.93 2.93
7
Ensures excellent patient care as well as resident learning Maintains resident’s status in the presence of the patient
2.88 2.88
9
Able to identify and select useful information from patient history and examination Able to select and interpret laboratory data
2.87 2.87
11
Shows interest in residents’ learning Shows enthusiasm for teaching Encourages active participation by resident
2.82 2.82 2.82
14
Serves as an expert consultant to resident Demonstrates differences of opinion in another room Settles differences of opinion in another room Gives positive feedback for positive behaviour
2.81 2.8 1 2.8 1 2431
................................................................................................. 61
Reviews medical record and residents’ written notes
2.29
62
Demonstrates willingness to stay late and not complain
2.12
Ratings: 3 = important, 2 = neutral, 1 = unimportant n = 17.
An inventory to improve clinical teaching
525
Table 4. WICT items rated differently by residents and attending doctors in rank order X2
Rank
Item
(df= 1)
(A) Items rated higher by residents than attending doctors 1 Settles disagreements by referring to literature Settles disagreements by negotiation
25.6. * 25.6* *
3
Demonstrates ability to organize and express ideas clearly Identifies and summarizes important elements in a case analysis
19.1** 19.1”;
5
Emphasizes important lessons to be drawn from a case analysis
11.5;’
6
Acknowledges and responds to residents’ questions
11.25**
7
Stimulates interest during case discussion Recognizes own limitations and errors
11.0** ll.O**
Questions residents to encourage thinking in different directions
10.28.
9
10
Questions residents to elicit their knowledge and judgements
6.0*
11
Demonstrates enthusiasm for teaching
5.1*
12
Clearly explains underlying basis for opinions and advice Questions residents to challenge their ideas Gives positive feedback for positive behaviour
4.57; 457* 4.57’
(B) Items rated higher by attending doctor than residents 1 Manages a ‘generalist’range of out-patient problems
45*
Attending physicians n = 9. Residents n = 8. * = P < 0.05. ** = P < 0,001. a year. The review sessions are entirely confidential and W I C T data d o not enter department files. (1) Evaluation ofthe W I C T . After each video review session, we interview participating teachers to evaluate the programme in general and the WICT in particular. We use semi-structured interviews and record the responses. We have obtained responses from eight of the nine participating teachers. This level of response suggests that attending doctors are unanimously and voluntarily committed t o continue in the programme and are satisfied with the instrument. O n e common comment (71%) is that the instrument represents the range of behaviours characteristic of appropriate teaching. The six roles ofattending doctors appeal t o some, but not all, of the teachers. According to one doctor, the categories could be limited to teaching, mentoring and consulting, as there is too much overlap of behaviours to warrant six separate categories. Another attending doctor commented: ‘These categories help m e conceptualize my role better and understand how it relates to practice’. A third
attending doctor stated: ‘The categories help me focus on my teaching, and the items allow me to think about aspects of m y teaching’. T h e length of time required to complete the instrument is, a doctor claims, ‘difficult to spare but is fully justified because I learn valuable things about m y teaching’. (2) The WICT as an instructional tool. The WICT has both an assessment and instructional
Table 5. Reliability scores for WICT using interitem correlations (internal consistency) based on the mean resident ratings for each attending doctor Cronbach’s a All items
0.97
Cotegory
Clinical role model Professional mentor Clinical supervisor Instructor Evaluator Consultant ~
n = 11
0.91 0.93
0.88 0-93 0.87 0.78
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M . C.A’B. Hewson G N.M . Jenson
role. One attending doctor suggested that respondents may benefit from using this instrument: ‘It could alert the residents to important behaviours that would contribute to their own teaching effectiveness’. It is our intention that this instrument educates attending doctors in the vocabulary and concepts of clinical teaching. The use of the WICT may be one way of facilitating learning by exposing respondents to the range of conceptions appropriate to teaching in the clinic. This exposure may lead to a sense of dissatisfaction with personal teaching behaviours, which in turn is a precondition for learning to take place (Hewson 1981).
teaching in the clinic needs further research. These differences suggest that residents and attending doctors have conflicting views about the type of teaching that should occur. Resolving this conflict may be important in improving residents’ satisfaction with their clinic rotations. We have postulated that an instrument such as the WICT, used in conjunction with a video review process, can promote learning about clinical teaching. At this point, our evidence for this is strong but anecdotal. We plan to report our findings of the evaluation of the teaching improvement programme in a subsequent paper. Conclusions
Limitations The inductive method of developing this instrument means that it may have limited generalizability. However, previously noted overlap with many of the items of the Irby (1977) and Skeff (1981) instruments suggests some generalizability to teaching on the wards. The validity of the instrument is threatened by the way in which some respondents limit their scale responses to one or two points. This problem suggests some strategies to improve the validity of the respondents’ ratings. These include: allowing busy, fatigued residents protected time in which to complete the W E T ; training respondents regarding the meaning of individual items; and ensuring that new residents (interns) have sufficient experience with their attending doctors before asking them to complete the questionnaire.
Future research The development of the instrument to assess appropriate teaching in the clinic is continuous. We anticipate that changes to the instrument will be made as we obtain further data. A larger sample will strengthen our analyses of validity, reliability and generalizability. The six roles of the attending doctor described in this study appear to be a useful construct. It would be of interest to check further the statistical validity of these roles through factor analytic techniques. The issue of the disparity between residents’ and attending doctors’ conceptions of
The inductive development of the W E T was based on qualitative descriptions of appropriate clinical teaching from the perspectives of both residents and attending doctors. A process involving progressive refinement of the original data led to an inventory of teaching behaviours which has been used as an instrument to assess teaching in .the clinic. Our data show that the inventory is valid and reliable. The instrument is clearly appropriate to the context of teaching residents in a clinic and differs from instruments designed to assess teaching on the wards. An assessment instrument such as the one described here makes it possible for clinical teachers to clarify their areas of strength and weakness. They are able to experience satisfaction from data confirming their positive teaching behaviours, and the provocative dissonance of becoming aware of behaviours that are negative. The instrument is a means for enhancing vocabulary and concepts about clinical teaching. It provides a stimulus that leads to learning a wider range of concepts of teaching by attending doctors and possibly residents as well. Acknowledgements The authors would like to thank Kelley Skeff M D PhD, Rebecca Byers M D and Judith Van Kirk MS for helpful advice in the writing of this paper. This work has been supported in part by USPHS/HRSA training grants 5D28-PE15218 and 5D28-PE55024 and the Research and Development fund of the Department of Medicine, University of Wisconsin.
An inventory to improve clinical teaching References Adams W.R., Ham T.H., Mawardi B.H., Scali H. A. & Weisman R. (1964) A naturalistic study of teaching in a clinical clerkship. Journal of Medical Education 39, 164-74. Foreman S. (1986) The changing medical care system. Journal of Medical Education 61, 11-21. Hewson P. W. (1981) A conceptual change approach to learning science. European Journal of Science Education 3 , 383-96. Irby D.M. (1977) Self assessment inventory for clinical and classroom teaching in medicine. Ofice of Research in Medical Education, School of Medicine, University of Washington. Irby D.M. (1986) Clinical teaching and the clinical teacher. Journal ofMedical Education 61, 35-45. Lawrence R.S. (1988) Goals for medical education in the ambulatory setting. Journal of General Internal Medicine 3, (Mar/Apr Suppl.), 515-20. Lincoln Y.S. & Guba E.G. (1985) Naturalistic Inquiry. Sage Publications, Beverly Hills, California. McPhee S.J., Mitchell T.F., Schroeder S.A., PerezStable E.J. & Bindman A.B. (1987) Training in a primary care internal medicine residency program. Journal of the American Medical Association 258, 1491-5.
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Perkoff G.T. (1986) Teaching clinical medicine in the ambulatory setting: an idea whose time may finally have come. N e w England Journal of Medicine 314, 27-3 1. SkeffK. (1981) The evaluation ofa method to improve the teaching performance of the attending physician. AmericanJournal of Medicine 75, 465-70. Strauss A. (1987) Qualitative Analysis for Social Scientists. Cambridge University Press, New York. Stritter F.T., Baker R.M. & McGaghie W.C. (1983) Congruence between residents’ and clinical instructors’ perceptions of teaching in outpatient centres. Medical Education 17, 385-9. Weinreb L., McGlynn T.J., Johnson T. & Monzendrider R.F. (1981) Faculty supervision of residents in an internal medicine practice. Journal of Medical Education 56, 1011-8. Wones R.G., Rouan G. W., Brody T.L., Bode R.B. & Radack K.L. (1987) An ambulatory medical education program for internal medicine residents. Journal of Medical Education 62, 47C-6.
Received 12 February 1990; editorial comments to authors 20 April 1990; accepted for publication 30 M a y 1990
An inventory to improve clinical teaching in the general internal medicine clinic M. G. A’B. HEWSON & N . M. JENSEN Department of Medicine, University of Wisconsin, Madison
Summary. The increasing occurrence of outpatient medical care has led to the need for more and better medical education in the clinic. The Wisconsin Inventory of Clinic Teaching (WICT) was developed to improve the teaching of attending doctors in a general internal medicine clinic. The items on the inventory were derived from interviews with residents and attending doctors. The inventory was shown to have validity, and to be reliable with internal consistency correlations. We found an interesting disparity between attending doctors’ and residents’ expectations concerning clinical teaching. The instrument is in use as part of a teaching improvement programme for attending doctors in a general internal medicine clinic.
doctors to see as many patients as possible), and logistical problems (the scheduling of patients in this time and space is complex). Under these circumstances, it is often difficult to coordinate good teaching with good patient care. In order to be improved, however, clinical teaching must be understood. Adams etal. (1964) used naturalistic research methods to study teaching in a clinical ward clerkship, analysing and then summarizing the descriptive data in terms of teaching behaviours. These profiles were used to generate an instrument to assess teachers’ behaviours. The instruments of Irby (1977) and Skeff (1981) both assess teaching on the wards and are significant developments in this area. An assessment instrument is needed, however, to deal with teaching in the clinic (Weinreb et al. 1981). Teaching in this setting is relatively undescribed and it is thus particularly important to develop an inventory of teaching behaviours grounded in descriptive data that are situationspecific and contextually sound (Strauss 1987). Such an instrument developed would thus be induced from detailed description rather than deduced from an educational theory or model. The approach taken to developing our instrument parallels that of Adams et al. (1964), but differs in that we developed our instrument specifically for the clinic setting.
Key words: teaching/*methods; *clinical competence; internal medicine/*educ; internship; Wisconsin
Introduction Changing hospital practices mean that more people receive their medical care as out-patients. It has thus become increasingly important for clinics to provide residency and clerkship training sites (Perkoff 1986; Foreman 1986; McPhee et al. 1987; Wones et al. 1987; Lawrence 1988). The clinic, however, presents many constraints on teaching. These include time constraints (patients are usually unwilling to spend a long time in the clinic), financial constraints (clinics are self-supporting and it is necessary for
Methods and results We developed this instrument in three phases: the development of the inventory ofteaching behaviours; the tests of validity and reliability; and the use of the instrument in a teaching improvement programme.
Correspondence: Mariana Hewson PhD, Clinical Sciences Center, 600 Highland Avenue, Madison, Wisconsin 53792, USA.
518
An inventory to improve clinical teaching Development of inventory
of clinical teaching
This phase involved collecting descriptive data from attending doctors and residents, and using these data to generate an inventory ofappropriate teaching behaviours. ( 1 ) Attending doctors’descriptions of teaching in the clinic. We initially conducted semi-structured interviews with 11 attending doctors at the University of Wisconsin, Department of Medicine, Section of General Internal Medicine about their teaching behaviours and their rationales for those behaviours. The participants included nine of the ten full-time academic staff members, one of the two part-time academic staff members and one fellow. The questions concerned four ‘staffing phases’ of attending doctors: behaviour in the conference room when reviewing the resident’s case analysis (history and physical examination, laboratory data, diagnosis and management plans); behaviour in the examination room with both the resident and patient; method of concluding with patient; and approach to supervising the completion of medical records. In addition, w e questioned the attending doctors about their opinions regarding the characteristics of, and constraints on, good teaching in the clinic. The interviews were recorded on audiotape and transcribed. We then analysed the data (transcripts) using qualitative, descriptive methods (Lincoln & Guba 1985; Strauss 1987). First, we analysed the transcripts for clear, coherent conceptions (single units of meaning). We then coded and categorized the conceptions. This method of data analysis resembles content analysis, but differs in several important ways: there is no attempt to formulate a rule, and the categories are produced inductively, not deductively, as there is no need for a priori guiding theory. In addition, the findings are specific to a given population and are not necessarily generalizable to other groups. These identified conceptions of teaching were thus self-reported attending doctor teaching behaviours.
(2) Residents’ description of teaching in the clinic. We interviewed all residents (a total of 28) in the clinic in small groups. We used semi-structured interviews to solicit residents’ ideas about which teaching behaviours of attending doctors they considered to be useful for learning. We also
519
asked about the characteristics of attending doctors w h o were good teachers, and the different types of instruction received. Audiotapes o f these group interviews were also transcribed and analysed as described above. The identified conceptions were put into the form of prescriptions for behaviour, such as ‘a good attending doctor should maintain the resident’s status in the presence of the patient in the examination room.’ Each resident received an abstracted list of appropriate teaching behaviours, and their agreement or disagreement with each item was checked. The list was then modified (for example, items with less than 50% agreement were removed). (3) Development of the inventory ofclinic teaching. We used the descriptive data of appropriate teaching behaviours from the perspectives of both the residents and attending doctors to generate an inventory of clinical teaching behaviours. This involved combining the two lists, removing redundant items, and differentiating the conflated items. The result was a list (inventory) of behaviours which both attending doctors and residents believed to be appropriate for teaching in the clinic. We eventually classified the items of the inventory in terms of six roles that appear to describe the staffing function of attending doctors in the clinic. This classification is similar to one suggested by Irby (1986). The six roles are: (a) clinical role model: the attending doctor displays attitudes, clinical knowledge and skills to the resident; (b) professional mentor: the attending doctor serves as a trusted counsellor to the resident; (c) clinical supervisor: the attending doctor aims to optimize patient care in the clinic; (d) instructor: the instructional methods are appropriate to the clinic; (e) evaluator: the attending doctor seeks feedback from and gives feedback to the resident. (Qconsultant: the attending doctor contributes experience and knowledge in patient care.
The inductive process used in the descriptive phase of this study is illustrated in Table 1. The verbatim descriptions of appropriate teaching behaviours by both attending doctors and residents serve as exemplars of a category of behaviour. Each exemplar is juxtaposed with the
M . G. A’B. Hewson G N.M . Jenson
520
Table 1. Selected verbatim comments of attending doctors (AD) and residents (R) obtained from preliminary descriptive study, with final item on WICT
Attending doctor (D)
Resident (R)
(1)
‘I think the residents can learn style from us, so I try sometimes to interact with the patient so that they (residents) will pick up on m y style because it’s different than some of the other doctors.’ RF.5
‘1 cannot think of a single attending who, if they feel strongly about something would not go back and show us the right w a y . . . and at those opportunities it is role modelling.’ R10
(1.1) Demonstrates how to manage a range of problems in the clinic.
(2)
‘I think (my approach) depends on whether they are PGl, 2 or 3s. With PGls 1 am more prone to imposing my way of doing things on them . . . I caught myself doing that with one of the PG3s the other day and by the way they were looking at me it seemed that they thought it was inappropriate. And I thought “Yeah, it probably is” and I should probably let them go on to tell me how they would approach it. So I think I’m more directive with PGls and less so with PG3s.’ LP.3
‘One important characteristic . . . is an attending who is willing to give you a fair amount of responsibility with the patient. . . I think, depending on how you have worked with them . . . (the AD) will realize if you need more supervision or not, and give a little more leeway to Rs who indicate (readiness). T8
(3.7) Adjusts amount of supervision to level of competence of residents.
(3)
‘As the Rs are presenting the problem obviously diagnostic considerations are going through my mind. . . so the questions I ask the residents are questions that 1 think would be helpful in better defining whatever is going on with the patient.’ LF.3
‘I think that we have a collegial type of relationship when we work through the patient together.’ R9
(4.3) Asks open-ended questions to explore ideas with residents (collegial teaching).
‘I think one of the nice things on this team is that attendings respect our opinions and they listen to what we say. If we have ideas of our own they don’t come out and say “No”, but they kind of guide you to possibly thinking that you came up with the ideas yourself.’ R5
(4.4)
(4) ‘If it’s an upper respiratory infection then he’ll say “In the throat I found such and such. I think we should get a culture and wait,” and then, you know, I’ll say “Well, do you think we should treat now?”, and then he’d say “I think we ought to treat now.” And then I’ll say “Well, did you check the heart for a murmur?” ’ RF.2
Questionnaire item
Questions resident to encourage thinking in different directions, when attending knows the answers.
An inventory to improve clinical teaching
52 1
Table 1 continued.
(5) ‘I have the residents pretty much present the case to me in as much detail as they desire, and then if there seem to be things missing, things I want to know, I ask them, “Do you know this”, “Do you know that?”, and either they do know i t and just didn’t mention it or they don’t know it, and we need to further investigate that. And then the next step is to ask them what they think is going on, trying to get a diagnosis from them. ’ JH. 1
‘Sometimes wejust say “We have such and such a disease and we are going to treat it like this.’’ And they will say ‘Why are you giving that test versus this test?” ’ R5
final item on the inventory, illustrating the way in which verbatim descriptions led to inventory items. The current version of the Wisconsin Inventory of Clinic Teaching (WICT) is presented in Table 2 in a condensed format. Measures of validity, reliability and generalizability
Measures were taken to establish validity, reliability and generalizability of the WICT. In the course of collecting validity data, we also observed differences between residents and attending doctors. (1) Validity of the inventory. An important component of qualitative analysis is to validate the derived categories of behaviour with the original subjects in the study (Lincoln & Guba 1985). To do this, we asked the teachers and residents to rate the importance of each item using a 3-point scale: important (3 points); neutral (2 points); and unimportant (1 point). Nine (all) of the participating full-time teachers and eight (of the 28) residents complied with this request. We calculated the mean ratings for each item for the group as a whole and also separately for the attending doctors and residents. The data showed 58 of the 62 items (93.5%) had mean ratings of more than 2.5. (We considered mean ratings between 2.5 and 3.0 to be important.) Three items (4.8%) had a mean rating between 2.25 and 2.19. We considered these to be margin-
(5.1) Questions residents to probe their knowledge and judgement.
ally important. One item (1.6%) had a rating between 2.0 and 2.49; we decided that this item was not sufficiently important to keep in the inventory. We combined and rephrased items to minimize redundancy, thus reducing the number of items to 46. The highest and lowest ranked items in terms of perceived importance by both the doctors and residents are listed in Table 3. The WICT has high face validity for both attending doctors and residents in the Department of Medicine, Section of General Internal Medicine at the University of Wisconsin, Madison. This is attributable to the inductive approach and verification of the inventory items with the participants in the study. The instrument satisfies all users concerning the appropriate teaching behaviours of attending doctors in the clinic. It does not deal with interactions that occur in class-rooms, personal offices or wards, since these were not the foci of our enquiry. (2) Reliability of the inventory. We established the reliability ofthe inventory by using a measure of internal consistency with inter-item correlations (Cronbach’s a) for the instrument as a whole and for the six roles (subcategories) described earlier. O u r hypothesis was that the instrument measures teaching in the clinic. T o do the inter-item correlation, we calculated the mean rating given to each participating attending doctor for each of the 43 inventory items. The results show particularly high a scores for the
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M . G. A’B. Hewson G. N.M . Jenson
Table 2. The Wisconsin Inventory of Clinic Teaching (WICT) For each of the following criteria, indicate how well you think your attending doctor’s (or your own) behaviour rates, using the scale: O= unable to judge unacceptable. clearly in need of help I = barely adequate, room for much improvement 2= 3= average, typical of a good attending doctor done very well, better than most 4= 5= outstanding, nearly perfect
1.10 1.11
The attending doctor as a clinical role model Demonstrates how to manage a range of problems in the clinic. Demonstrates good patient interviewing skills. Demonstrates humanistic attitudes in relating to patients (integrity, compassion and respect). Displays technical skills pertaining to ambulatory primary care. Displays knowledge about and use of current literature pertaining to patient problems. Displays knowledge about availability and role of the spectrum of health services (PT, OT, RT, Social Work, Home Health Services, Employee Health, Nursing Homes, etc.). Displays willingness and ability to work as a team with other health professionals. Displays knowledge that is grounded in clinical experience. Displays knowledge of psychosocial aspects of medicine. Shows commitment to continued personal learning and development. Recognizes personal limitations and errors.
2.0 2.1 2.2 2.3 2.4 2.5 2.6
The aftending doctor as a professional mentor Is available for additional teaching when requested by residents. Shows sensitivity to resident’s feelings. Is available, approachable and receptive to residents’ personal problems. Inspires confidence in resident to solve clinical problems. Is enthusiastic about challenges of practice. Coaches residents in affective (emotional) aspects of medical practice.
3.0 3.1 3.2 3.3 3.4
The attending doctor (12 a clinical supervisor Promotes a cost-oriented approach to clinical problems. Uses consultants in subspecialties judiciously. Promotes good patient education by resident. Promotes keeping of medical records in a way that is thorough, legible, efficient and organized. Promotes continuity of care. Checks the validity of the resident’s history and physical findings directly with the patient. Adjusts amount of supervision to level of competence of residents. Communicates effectively the attending doctor’s expectations of residents . Reviews the adequacy of the patient management plan with resident. Demonstrates responsible time management when staffing residents.
1.0 1.1 1.2 1.3 1.4 1.5 1.6
1.7 1.8 1.9
3.5 3.6 3.7 3.8 3.9 3.10 4.0 4.1 4.2 4.3
T h e attending doctor as instructor Demonstrates enthusiasm for teaching in clinic. Engages in didactic teaching when resident’s responses indicate a need. Asks open-ended questions to explore ideas with residents (collegial teaching).
Rating
1 1 1 1 1 1
I 1 1 1 1
1 1 1 1 1 1 1 I 1 I
I I I 1 I I
I I 1
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523
Table 2 continued. 4.4 4.5 4.6 4.7 4.8 4.9 4.10 4.11 5.0 5.1 5.2
5.3 5.4 5.5
6.0 6.1 6.2 6.3
Questions resident to encourage thinking in different directions. Encourages residents to participate actively in diagnosis and management plan. Clearly and logically explains underlying basis for hidher opinions and advice. Identifies and emphasizes important elements in case analysis. Adjusts instructional approach to different levels of resident training. Demonstrates a flexible, open-minded approach to alternative suggestions by residents. Promotes reflection on clinical practice. Uses relevant scientific literature o r authoritative sources in supporting hidher clinical advice.
I
1
[ [
I I
The attending doctor as evaluator Questions residents to probe their knowledge and judgements. Asks residents to justify statements if perceived as wrong by attending doctor. Provides constructive criticism for inappropriate behaviours. Gives positive feedback for appropriate behaviours. Gives timely feedback to residents.
The attending doctor as consultmi Is available for consultation when requested by resident. Gives expert advice when resident is uncomfortable with a case. Maintains the resident’s status in presence of the patient, i.e. does not unnecessarily take over the case.
whole instrument. This gives us confidence that we are measuring appropriate teaching behaviours. In addition, the high scores for the six roles suggest that they are coherent entities. This result suggests further investigation concerning the roles o f the attending doctor in staffing residents. The inter-item correlations are presented in Table 4. (c) Generalizability of the inventory. At this point, the instrument represents clinic teaching in the Section o f General Internal Medicine at the University of Wisconsin, Madison, and may not be generalizable to other sites. It was, however, compared to the assessment instruments for teaching on in-patient wards developed by Skeff (1981) and Irby (1977), both ofwhich have made claims for reliability and validity. We found that 80% and 85% of the items in the respective instruments also occur in the WICT. This reinforces our claims of content validity, and suggests that the instrument may be generalizable to other settings. The major finding of the comparison to the
Irby and Skeff instruments was that the WICT has additional items that reflect medical practice in the clinic. These include practising in a team with allied health professionals, knowledge of psychosocial aspects of medicine, promoting patient education, and continuity of care. The WICT includes some additional instructional items (such as collegial teaching and reflective teaching) and evaluation items (such as requiring residents to justify statements). Some of these additional items reflect previously published characteristics of teaching in the clinic (Perkoff 1986; McPhee 1987). (4) Data f r o m validity studies. We observed an interesting disparity in the responses ofattending doctors and residents to some of the WICT items. As a result w e calculated xz o n the rating frequencies for each item, for the two groups. These were 2 x 2 tables since none of the items was rated as unimportant. Comparisons shown to be significantly different are listed in Table 5. These differences suggest that residents consider some instructional items to be more important
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M . G. A’B. Hewson G N.M.]enson
than the attending doctors do. For example, residents value the following instructional behaviours more than attending doctors do: ‘demonstrates ability to organize and express ideas clearly’; ‘identifies and summarizes important elements. in a case’; ‘acknowledges and responds to residents’ questions’; ‘stimulates interest during case discussions’; ‘questions residents to encourage thinking in different directions’ and ‘to elicit their knowledge’. T h e item rated most differently concerned the settling of disagreements between the residents and attending doctors. O n the other hand, attending doctors showed a significantly higher rating o n one item: ‘manages a “generalist” range of out-patient problems’. It thus appears that residents have high expectations of attending doctors as instructors, which does not appear to be shared by the attending doctors. These results conflict with those of
Stritter et al. (1983), who suggested concordance between teacher and house staff views o n teaching in ambulatory medicine. This disparity dexrves further investigation.
Use ofthe WICT in a teaching improvement programme Along with reviews of videotapes of teaching interactions in the clinic, the W I C T is used in a teaching improvement programme. This process is similar t o the intensive feedback method of Skeff (1981). Attending doctors assess their own peformance using the WICT, and are assessed by their regular residents. The clinical teaching specialist analyses the W I C T data and presents a written report t o each attending doctor. This report provides a focus for the video review session. Attending doctors take part in the teaching improvement programme at least once
Table 3. Appropriate teaching behaviours suggested by both attending doctors and residents in rank order Rank
Item
Mean rating
1
Demonstrates how to manage a range of problems in the clinic
3.00
2
Ability to maintain a positive relationship with resident independent of resident’s level of knowledge and skill
2.96
3
Demonstrated humanistic attitudes in relating to patients Demonstrates concern for patient’s feelings
2.94 2.94
5
Competent in analysing patient’s problems Able to identify the central issues of a case
2.93 2.93
7
Ensures excellent patient care as well as resident learning Maintains resident’s status in the presence of the patient
2.88 2.88
9
Able to identify and select useful information from patient history and examination Able to select and interpret laboratory data
2.87 2.87
11
Shows interest in residents’ learning Shows enthusiasm for teaching Encourages active participation by resident
2.82 2.82 2.82
14
Serves as an expert consultant to resident Demonstrates differences of opinion in another room Settles differences of opinion in another room Gives positive feedback for positive behaviour
2.81 2.8 1 2.8 1 2431
................................................................................................. 61
Reviews medical record and residents’ written notes
2.29
62
Demonstrates willingness to stay late and not complain
2.12
Ratings: 3 = important, 2 = neutral, 1 = unimportant n = 17.
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525
Table 4. WICT items rated differently by residents and attending doctors in rank order X2
Rank
Item
(df= 1)
(A) Items rated higher by residents than attending doctors 1 Settles disagreements by referring to literature Settles disagreements by negotiation
25.6. * 25.6* *
3
Demonstrates ability to organize and express ideas clearly Identifies and summarizes important elements in a case analysis
19.1** 19.1”;
5
Emphasizes important lessons to be drawn from a case analysis
11.5;’
6
Acknowledges and responds to residents’ questions
11.25**
7
Stimulates interest during case discussion Recognizes own limitations and errors
11.0** ll.O**
Questions residents to encourage thinking in different directions
10.28.
9
10
Questions residents to elicit their knowledge and judgements
6.0*
11
Demonstrates enthusiasm for teaching
5.1*
12
Clearly explains underlying basis for opinions and advice Questions residents to challenge their ideas Gives positive feedback for positive behaviour
4.57; 457* 4.57’
(B) Items rated higher by attending doctor than residents 1 Manages a ‘generalist’range of out-patient problems
45*
Attending physicians n = 9. Residents n = 8. * = P < 0.05. ** = P < 0,001. a year. The review sessions are entirely confidential and W I C T data d o not enter department files. (1) Evaluation ofthe W I C T . After each video review session, we interview participating teachers to evaluate the programme in general and the WICT in particular. We use semi-structured interviews and record the responses. We have obtained responses from eight of the nine participating teachers. This level of response suggests that attending doctors are unanimously and voluntarily committed t o continue in the programme and are satisfied with the instrument. O n e common comment (71%) is that the instrument represents the range of behaviours characteristic of appropriate teaching. The six roles ofattending doctors appeal t o some, but not all, of the teachers. According to one doctor, the categories could be limited to teaching, mentoring and consulting, as there is too much overlap of behaviours to warrant six separate categories. Another attending doctor commented: ‘These categories help m e conceptualize my role better and understand how it relates to practice’. A third
attending doctor stated: ‘The categories help me focus on my teaching, and the items allow me to think about aspects of m y teaching’. T h e length of time required to complete the instrument is, a doctor claims, ‘difficult to spare but is fully justified because I learn valuable things about m y teaching’. (2) The WICT as an instructional tool. The WICT has both an assessment and instructional
Table 5. Reliability scores for WICT using interitem correlations (internal consistency) based on the mean resident ratings for each attending doctor Cronbach’s a All items
0.97
Cotegory
Clinical role model Professional mentor Clinical supervisor Instructor Evaluator Consultant ~
n = 11
0.91 0.93
0.88 0-93 0.87 0.78
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M . C.A’B. Hewson G N.M . Jenson
role. One attending doctor suggested that respondents may benefit from using this instrument: ‘It could alert the residents to important behaviours that would contribute to their own teaching effectiveness’. It is our intention that this instrument educates attending doctors in the vocabulary and concepts of clinical teaching. The use of the WICT may be one way of facilitating learning by exposing respondents to the range of conceptions appropriate to teaching in the clinic. This exposure may lead to a sense of dissatisfaction with personal teaching behaviours, which in turn is a precondition for learning to take place (Hewson 1981).
teaching in the clinic needs further research. These differences suggest that residents and attending doctors have conflicting views about the type of teaching that should occur. Resolving this conflict may be important in improving residents’ satisfaction with their clinic rotations. We have postulated that an instrument such as the WICT, used in conjunction with a video review process, can promote learning about clinical teaching. At this point, our evidence for this is strong but anecdotal. We plan to report our findings of the evaluation of the teaching improvement programme in a subsequent paper. Conclusions
Limitations The inductive method of developing this instrument means that it may have limited generalizability. However, previously noted overlap with many of the items of the Irby (1977) and Skeff (1981) instruments suggests some generalizability to teaching on the wards. The validity of the instrument is threatened by the way in which some respondents limit their scale responses to one or two points. This problem suggests some strategies to improve the validity of the respondents’ ratings. These include: allowing busy, fatigued residents protected time in which to complete the W E T ; training respondents regarding the meaning of individual items; and ensuring that new residents (interns) have sufficient experience with their attending doctors before asking them to complete the questionnaire.
Future research The development of the instrument to assess appropriate teaching in the clinic is continuous. We anticipate that changes to the instrument will be made as we obtain further data. A larger sample will strengthen our analyses of validity, reliability and generalizability. The six roles of the attending doctor described in this study appear to be a useful construct. It would be of interest to check further the statistical validity of these roles through factor analytic techniques. The issue of the disparity between residents’ and attending doctors’ conceptions of
The inductive development of the W E T was based on qualitative descriptions of appropriate clinical teaching from the perspectives of both residents and attending doctors. A process involving progressive refinement of the original data led to an inventory of teaching behaviours which has been used as an instrument to assess teaching in .the clinic. Our data show that the inventory is valid and reliable. The instrument is clearly appropriate to the context of teaching residents in a clinic and differs from instruments designed to assess teaching on the wards. An assessment instrument such as the one described here makes it possible for clinical teachers to clarify their areas of strength and weakness. They are able to experience satisfaction from data confirming their positive teaching behaviours, and the provocative dissonance of becoming aware of behaviours that are negative. The instrument is a means for enhancing vocabulary and concepts about clinical teaching. It provides a stimulus that leads to learning a wider range of concepts of teaching by attending doctors and possibly residents as well. Acknowledgements The authors would like to thank Kelley Skeff M D PhD, Rebecca Byers M D and Judith Van Kirk MS for helpful advice in the writing of this paper. This work has been supported in part by USPHS/HRSA training grants 5D28-PE15218 and 5D28-PE55024 and the Research and Development fund of the Department of Medicine, University of Wisconsin.
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Perkoff G.T. (1986) Teaching clinical medicine in the ambulatory setting: an idea whose time may finally have come. N e w England Journal of Medicine 314, 27-3 1. SkeffK. (1981) The evaluation ofa method to improve the teaching performance of the attending physician. AmericanJournal of Medicine 75, 465-70. Strauss A. (1987) Qualitative Analysis for Social Scientists. Cambridge University Press, New York. Stritter F.T., Baker R.M. & McGaghie W.C. (1983) Congruence between residents’ and clinical instructors’ perceptions of teaching in outpatient centres. Medical Education 17, 385-9. Weinreb L., McGlynn T.J., Johnson T. & Monzendrider R.F. (1981) Faculty supervision of residents in an internal medicine practice. Journal of Medical Education 56, 1011-8. Wones R.G., Rouan G. W., Brody T.L., Bode R.B. & Radack K.L. (1987) An ambulatory medical education program for internal medicine residents. Journal of Medical Education 62, 47C-6.
Received 12 February 1990; editorial comments to authors 20 April 1990; accepted for publication 30 M a y 1990
