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Table of Contents
ORIGINAL RESEARCH
Year : 2019  |  Volume : 2  |  Issue : 2  |  Page : 91-97

Part II: Observations of clinical teaching in the veterinary teaching hospital


1 Department of Small Animal Clinical Sciences, College of Veterinary Medicine; Department of Family, Youth and Community Sciences, College of Agricultural and Life Sciences, University of Florida, Gainesville, FL, USA
2 Department of Family, Youth and Community Sciences, College of Agricultural and Life Sciences, University of Florida, Gainesville, FL, USA
3 Department of Large Animal Clinical Sciences, College of Veterinary Medicine, Gainesville, FL, USA
4 Department of Small Animal Clinical Sciences, College of Veterinary Medicine, Gainesville, FL, USA

Date of Web Publication5-Nov-2019

Correspondence Address:
Dr. Candice Stefanou
University of Florida, Gainesville, FL
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/EHP.EHP_19_19

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  Abstract 


Background: Clinical education is uniformly considered an essential phase of training in all health professions, yet our understanding of the nature of clinical teaching is limited, including how teaching responsibilities are distributed among various teaching staff available. This study documents variety of teaching techniques used in the clinics of a veterinary teaching hospital and explores the teaching roles that are assumed by the clinical staff. Methods: Nearly 115 h of structured observations of clinical teaching in 11 different clinical services was evaluated. Results: Faculty and residents engaged in different but complementary teaching behaviors with the students. House officers were most likely to demonstrate their clinical reasoning for the students and respond to student questions. Faculty, on the other hand, primarily asked students questions. Providing opportunities for students to observe professionals demonstrating clinical problem-solving and decision-making and questioning and answering questions were the dominant teaching techniques. All teachers took opportunities to extend student learning by taking advantage of the “teaching moment” as the fourth most frequent teaching technique observed. Conclusion: Results suggest that, while a variety of valuable teaching techniques are utilized, there could be more opportunities for students to practice decision-making under the supervision of seasoned professionals.

Keywords: Clinical education, clinical teaching, medical education, veterinary education


How to cite this article:
Stefanou C, Moore K, Samper J, Conner B, McConkey M, Aherne M. Part II: Observations of clinical teaching in the veterinary teaching hospital. Educ Health Prof 2019;2:91-7

How to cite this URL:
Stefanou C, Moore K, Samper J, Conner B, McConkey M, Aherne M. Part II: Observations of clinical teaching in the veterinary teaching hospital. Educ Health Prof [serial online] 2019 [cited 2019 Nov 13];2:91-7. Available from: http://www.ehpjournal.com/text.asp?2019/2/2/91/270287




  Introduction Top


Clinical teachers recognize that there is a delicate balance needed between providing high-quality health care to patients and providing continuous education for veterinary students. Clinicians need to strike that balance for the benefit of the clients and patients, the hospital's ability to maintain financial solvency, and the education of the next generation of competent and confident practitioners. As Lane and Strand [1] noted, there are multiple and increasing demands on medical education, not the least of which are the need to contain costs and an increased emphasis on producing research. Even so, Lane and Strand [1] found that faculty generally believe the clinical rotation model to be an effective model of education. Some of the key factors that faculty noted in their study were the hands-on nature of clinical rotations, the ability of students to interact directly with clients and patients, the opportunity for formulating differential diagnoses, the ability for students to receive feedback from faculty, and a sense of autonomy and ownership that derives from that direct patient and client care and interaction. Lane and Strand [1] also noted that the clinicians placed great value on the other clinical staff in the clinic setting, including house officers and veterinary technicians. Parsell and Bligh [2] noted that “an effective use of time, both with and without patients, and an ability to recognize and seize teaching moments, are essential” for the clinical educator. Our study focuses on what techniques are used by whom on the clinic floor and the frequency with which they are used to provide a picture of the teaching moments.

As Daelmans et al.[3] noted, “the clinical setting is a highly complex learning environment that is not easy to study. It is therefore not surprising that research into clerkship learning is difficult and sparse.” Our review of the literature resulted in a handful of qualitative studies on students and faculty experiences of the educational aspects of the clinical setting;[1] several survey studies on what makes a good clinical teacher as seen from both faculty and student perspectives;[4],[5] and another set of papers that advocate for a constellation of teacher behaviors and attributes that are thought to be what good clinical teachers do.[6],[7],[8] We were able to find only one study using direct observation of clinical teaching in human medicine [9] and a handful of observational studies that focused on rounds, but again in human medicine.[10],[11],[12]

Despite the expressed importance of the clinical rotation as an environment for students to develop a growing sense of autonomy with regard to medical decision-making,[1] much of the research on teaching in the clinics documents that clinical education is still predominantly teacher-directed and academic in nature.[10],[12] Foley et al.[10] and Walton and Steinert [12] found that the faculty tend to dominate communication in the clinical setting and that much of the interaction with students is information dissemination and of a low level. Further, they found faculty questioning of residents and interns to be factual in nature and about patient care.[10],[12] One conclusion was that, when difficult, clinical teachers should consider how to facilitate students' problem-solving in the unpredictable clinical setting by engaging in higher level information sharing and questioning.[10] The results of Stickrath et al.'s [11] study on medical rounds fall in line with these earlier works, with the most common educational activities observed being answering questions pertaining to patient care and information dissemination related to medical content. Residents also serve the role of teacher in the clinical setting. The one study that suggests that faculty do more problem-solving activities is the study of Tremonti and Biddle [9] who studied whether residents and faculty engage with students differently in their roles as teachers. They found that faculty engaged in problem-solving activities where residents engaged in more day-to-day patient management as a form of teaching.

Significant portions of veterinary medical education happen in the traditional classroom and laboratory setting, and there is anecdotal evidence that currently veterinary educators are giving significant attention to active learning methods, such as team-based learning or flipped classrooms. The traditional classroom and laboratory context allows the educator to use the structured environment to carefully craft active learning experiences. The authenticity of the clinical context can be capitalized on other active learning models, such as those suggested by situated learning and cognitive apprenticeship learning theories.[13],[14],[15],[16]

The existing body of empirical evidence provided from observational studies of human medicine and veterinary medicine educational settings is not enough to allow us to generalize or draw conclusions about the nature of teaching in the clinic. Considering the relative scarcity of information about the nature of teaching in the clinical setting, this observational study can provide a much-needed exploration of what teachers are observed to do in the clinical setting of a veterinary teaching hospital. The focus of this study was to observe who was doing the majority of the teaching in the clinical setting, to note the teaching techniques that were used most often and by whom (clinical faculty, house officers, and veterinary technicians), and determine who interacted as a teacher for each learner (students and house officers).


  Methods Top


Procedure

Trained observers collected data on 12 types of educational interactions in 11 veterinary hospital clinical services during a 3-week period (IRB201801174). We used a combined inductive and deductive approach to identify the 12 types of educational interactions or “teaching techniques” that are the focus of this study. We selected some teaching techniques based on a previous study suggesting specific types of interactions that would be expected to be seen in a veterinary clinical setting, such as demonstrating technical procedures, for example.[17] Other interactions reflecting a form of teaching were identified during the training process in which the observers and methodologists watched recordings of clinical services. Prior to formal observations and data collection, the observers and methodologists in the study met for approximately 5 h to view videotapes of clinical teaching in the veterinary hospital where the observations would later occur. The recordings were made in the primary care and dentistry clinic and were done on different days and times of day to capture a range of potential teaching activity. The team practiced using the observation tool created for the study to calibrate our interpretations of what we were observing to ensure consistent use of the observation instrument. Only when we concluded that we had a shared understanding of how to determine the presence of each teaching technique, based on discussion and consistent documentation during these practice sessions, did formal observation and data collection begin.

Observations occurred over a 3-week period at one veterinary teaching hospital. The curriculum of the veterinary education program requires students to complete each clinical rotation in 2-week blocks of time. Therefore, observing over 3 weeks allowed us to capture the second of 2 weeks of some clinical rotations and the first and second week of other clinical rotations. Observations occurred in 11 clinical services over a 3-week period and amounted to 114.75 h of observations [Table 1]. Only one observer was present at a time in each clinical service observed. Both observers at some point observed each service, except for Food Animal Medicine and Reproduction and Zoo Medicine. Observations included morning, midday, and late afternoon time blocks, Monday through Friday, in order to capture any variation due to the day of the week or time of the day. All observations were in the service clinics where procedures or consultations between the students, teachers, and on occasion, clients, took place. Observers did not attend rounds.
Table 1: Services observed and hours of observation

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Participants

We approached the service chiefs of 19 services to allow us to approach the staff and students in the service to participate in the study. Eleven service chiefs accepted the invitation to participate, two declined the invitation, and six failed to respond. For those services where the service chief provided assent, we approached each person present in the rotation on the days of observation to obtain informed consent before data collection began. Participants included students, veterinary technicians, house officers (interns and residents), and clinical faculty. Demographic information for participants was not collected, given the dynamic nature of the observational process; however, participants were representative of the faculty, staff, and student demographics observed in most large veterinary teaching hospitals within the United States.

Data collection

We collected data using an observation instrument created for this study. Observations were organized around interactions between students and a teacher figure. Teacher figures include clinical faculty, house officers, veterinary technicians, or, in rare cases, another student. For a given student, we observed the teaching techniques utilized during a teaching “event” occurring between the student and a teacher figure. A teaching event was defined as the totality of an educational interaction between a student and a teacher figure initiated either by a student or by a teacher figure for the purpose of instruction (interactions that were social in nature were not included as part of the observations). For example, the event would begin when a student started discussing a case with a teacher figure and would end when the discussion concluded. Multiple teaching techniques could be utilized and observed within a single teaching event. It is important to note that house officers (intern or resident) served in the dual capacity of students and teacher figures depending on the nature of the interaction. House officers could not be both the teacher and student in a single event, rather they were considered the student when the teaching event was occurring for the purpose of their learning, and they were the teacher when fulfilling this role during an interaction. It is possible that the same individual was observed in multiple teaching events and was considered the student in some and the teacher figure in others. This did not create a problem for this particular study as we were not concerned with the experience of an individual student, but rather we were interested in characterizing the types of teaching techniques utilized in veterinary medicine education generally, across student and teacher figures.

The 12 teaching techniques being observed in this study were derived from previous research and the training videos used to calibrate the instrument. Teaching techniques are categorized into four broad pedagogical areas of (a) knowledge exchange, (b) reasoning, (c) feedback, and (d) professional competencies, with three techniques in each category. For each interaction observed, the observers noted who the student was in each teaching event (veterinary student or house officer), who the teacher figure was (faculty, house officers, veterinary technicians, or another student), and the teaching technique(s) observed and under what conditions. Conditions recorded include contextual elements (skill being practiced, service, etc.) and any other individuals present for the teaching event. [Table 2] provides the type of data collected. [Table 3] provides the teaching techniques targeted for observation. It should be noted that teaching techniques 5, 8, and 9 are undesirable techniques, so we hoped to see low use of those.
Table 2: Types of data collected

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Table 3: Teaching techniques

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Analysis

Data analysis was descriptive in nature, noting the proportion of the teaching events in which each veterinary teacher group acted as the “teacher” and which of the teaching techniques each group primarily utilized. Frequency counts, proportion of teaching events, and correspondence analysis constituted the analyses to answer the following:

  • What teacher group is doing the majority of the teaching?
  • Are all techniques used by all teaching groups?
  • What are the teaching techniques used most frequently in clinical education at our hospital?
  • What teachers (veterinary technicians, house officers, and clinical faculty) are using which teaching techniques?
  • Who interacts as a teacher for each learner (students and house officers) and are faculty more likely to be the teacher when the learner is a house officer rather than a DVM student?
  • Regarding the roles the house officers take, in what percentage of the observations are they acting as students? In what percentage as teachers?



  Results Top


What teacher group is doing the majority of the teaching?

The frequency of the number of teaching events done by the three teaching groups indicated that proportionally, clinical faculty were observed to lead significantly more teaching events (44.6%) than either the house officers (23.9%) or the veterinary technicians (21.1%). From time to time, students acted as a teacher to another student (10.4%) [Figure 1]. Students as teachers are disregarded in subsequent analyses.
Figure 1: Proportion of teaching events for each teaching group

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Are all techniques used by all teaching groups?

The percentages below show the proportion of the 12 teaching techniques each teacher group uses. The data show that faculty are using more of the teaching techniques (44.4%) than either the house officers (23.9%) or the veterinary technicians (21.2%) [Figure 2]. Faculty are utilizing nearly twice as many techniques in their teaching as either of the other two groups of potential teachers in the clinic.
Figure 2: Proportion of all techniques used by each teaching group

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What are the teaching techniques used most frequently in veterinary clinical education?

The most frequently observed teaching techniques and the percentage of their occurrence for all teacher groups combined in order of use were teachers actively demonstrating their clinical reasoning (4; 20.4%), student questioning (2; 18.1%), teacher questioning (1; 13.3%), and teachers extending student understanding by taking advantage of a teachable moment through extended discussion and elaboration (3; 11.1%) [Figure 3]. Teachers actively demonstrating their clinical reasoning meant the teachers were talking through the logic of their choices and actions so students could observe their thought process. The student questioning code referred to when the students asked focused questions exploring the logic used by the teacher figure to come to decisions. On the contrary, teacher questioning referred to instances when teacher questioning of the student served a scaffolding technique to help the students reach a conclusion on their own. Teachable moments were opportunities seized by the teacher figure to discuss topics beyond that of what was immediately necessary given the current case. For example, a student analyzing a case may recognize symptoms, which prompts a conversation about the physiological reason for those symptoms.
Figure 3: Proportion of use of each teaching technique overall

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The remaining techniques occurred at much lower frequencies, <10% of total observations for each. These were teachers nonverbally confirming student work (9), teachers teaching a technical skill (12), teachers making clinical decisions without explaining (5), teachers engaging in collaborative reasoning with a student (6), teachers correcting students and providing an explanation (7), teachers correcting students without providing an explanation (8), teachers articulating the next steps to take (10), and teachers demonstrating a technical skill to a student (11).

Which teaching techniques are being used by the different groups of teachers (veterinary technicians, house officers, and clinical faculty)?

There are clear differences in which techniques were observed occurring more frequently among the three teaching groups. Clinical faculty ask students more questions; house officers demonstrate more active reasoning (explain what they are doing and why) and articulate their next steps; and veterinary technicians do most technical instruction in the clinical rotations. The remaining teaching techniques were observed to occur equally across the three teaching groups [Figure 4].
Figure 4: Proportion of use of each teaching technique and the teachers who use themwho use them

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Who interacts as a teacher for each learner (students and house officers) and are faculty more likely to be the teacher when the learner is a house officer rather than a student?

This question is posed from the student's point of view. In other words, how is time spent in educational interaction distributed across all three teaching groups for each learner group. When the student is the learner, faculty are observed to be the teacher approximately 45% of the time, house officers are the teacher approximately 23% of the time, and veterinary technicians are the teacher approximately 32% of the time. When the house officer is considered the learner, faculty are observed to be the teacher approximately 61% of the time, another house officer is the teacher approximately 36% of the time, and a veterinary technician is the teacher approximately 3% of the time [Figure 5].
Figure 5: Proportion of time each teaching group interacted with a learner group as the teacher

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Regarding the roles the house officers take, in what percentage of the observations are they acting as students? In what percentage as teachers?

The data show that while house officers nearly split their time in half between teaching and being taught, they spend more of their time as a learner [Figure 6].
Figure 6: Proportion of time house officer acted as student and teacher

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  Discussion Top


Interest in capturing the dynamic conditions of teaching and learning on the clinic floor has been ongoing for decades. That so much is still unknown and the lack of robust literature attests to just how difficult a task this has proven to be. Previous studies focused on the quality of interactions between teachers and students in the clinical setting, more specifically during rounds. There is anecdotal evidence that rounds are thought by students and faculty alike to be the primary point for teaching during the clinical rotation, perhaps because they are scheduled and, in that sense, controllable. It is also acknowledged that there is value in taking advantage of the “teaching moment” in the fast-paced setting of the clinic floor and great interest in finding ways to make that happen.[3] However, in doing so, there is still the need to maintain high-quality patient care and honor the fiduciary responsibility to the hospital. This study took us onto the often-unpredictable environment of the clinic floor.

While previous studies focused primarily on communication patterns, our study included ways teachers and students communicate with each other for an educational purpose, but we also observed other forms of teaching in the clinic. We observed for instances of collaborative and critical reasoning exchanges, provision of feedback, and demonstration and teaching of technical skills. By adding these dimensions, this works extends earlier work. Foley et al.'s study on communication patterns [10] and Walton and Steinert's [12] and Stickrath et al.'s [11] study on content of communications found that faculty communicated through information dissemination, as in rounds and lectures, and the information disseminated was fact based and questions posed were low level. Our results showed that the three dominant teaching techniques used by faculty were having students observe a professional demonstrating clinical problem-solving and decision-making (technique #4) and questioning where students ask questions (technique #2) or where students are asked questions (technique #1). While we did not collect data on the level of the questioning, we do see that questioning remains a high frequency practice for teaching in the clinics. We also see that student observation remains a frequently used teaching technique. Our observations included the clinician actively sharing their problem-solving and clinical decision-making with the students while the students observed, perhaps suggesting the use of a cognitive apprenticeship model in the clinic.[13]

Lyons et al.[14] examined the use of cognitive apprenticeship as a model in health science education research. They describe cognitive apprenticeship as “a set of approaches to teaching based on the situated learning theoretical framework with an emphasis on: (1) pedagogical strategies that experts use to teach complex tasks; and (2) cognitive and metacognitive processes and skills required for expertise.”[14] Lyons et al.[14] concluded that faculty in the health sciences use some aspects of the cognitive apprenticeship model, and that the way faculty use cognitive apprenticeship is not entirely consistent with the theoretical model. We do not know if our teachers in the clinic are using a true cognitive apprenticeship model or a variation as Lyons et al.[14] found through their review of the literature. Studying how clinicians model their problem-solving and decision-making would add to the literature on clinical education and provide a point of departure for professional development programs for clinical teaching faculty.

Our observations also validate some aspects from our perception study.[17] We found that, consistent with perceptions of graduating students, residents, and veterinary technicians, house officers were the teachers who demonstrated their clinical reasoning for the students and responded to their questions. These findings are consistent with our earlier study in terms of high value, high frequency, and house officer as the teacher. Faculty, on the other hand, were the ones primarily asking students questions; they responded to students' questions at about the same rate as they asked questions. All three teaching groups took opportunities to extend student learning by taking advantage of the “teaching moment” as the fourth most frequent teaching technique observed (technique #3).

We found some things that were inconsistent with earlier work as well. Earlier studies commented on the lack of time spent in problem-solving in clinical teaching.[10] Our results indicate that in this veterinary teaching hospital, teachers pay considerable attention to actively demonstrating clinical problem-solving and decision-making to students (technique #4) and somewhat less of making thought processes visible by articulating the next steps for the case (technique #10). However, students' roles were still as observers. This is significant because of the universal recognition of the role played by hands-on learning and this is especially critical during the clinical training phases of veterinary medical education. Lane and Strand [1] noted that faculty uniformly hold that supervising students as they work with patients is one of the most valuable learning experiences in the clinic. In addition to the obvious value of being responsible for clinical decision-making, students receive immediate feedback from the clinician in real time. The teaching technique in our study most closely aligned with the idea of supervised practice occurs when students and teachers in the clinic collaborate to make clinical decisions (technique #6). In our study on perceptions of students and clinical staff and faculty, we found that all groups placed high value on collaborative problem-solving and decision-making, but, aside from students who were about to enter the clinics, all the others believed it occurred infrequently. Our observations are in support of the frequency estimates from our earlier study.[17] This particular teaching technique was one of the least occurring techniques during our observations, suggesting that this could be where we focus our professional development activities and use the modeling and questioning techniques that we do routinely to scaffold student development toward their progress of becoming independent practitioners. We did find, however, that there is considerable teaching of technical skills (technique #12), even more so than demonstrating a technical skill. Further, this teaching is almost exclusively done by the veterinary technicians. Our observations of faculty, house officers, and veterinary technicians suggest that our teachers in the clinics also assume complementary roles,[9] even though there is some overlap between faculty and house officers.

Another area where we found inconsistent findings with our perception study is in who is doing the bulk of the teaching in the clinics. The perception was that the house officers were the ones doing the bulk of the teaching in the clinics.[17] The results of our observations suggest that the faculty in fact do most of the teaching and use a greater percentage of the techniques overall. Our observations say that faculty account for approximately 45% of the teaching, house officers account for approximately 24%, and veterinary technicians account for approximately 21% of the teaching in the clinics. Although all groups of teachers use all teaching techniques, faculty utilize more frequently #1 (asking students questions) and 9 (providing nonverbal confirmation) compared to residents who use #4 (demonstrating active reasoning), 10 (articulating the next steps), and 11 (demonstrating a technical skill) with higher frequency. Technicians relied on #12 (teaching a technical skill) as teaching techniques.

We recognize that this does not encompass a complete picture of teaching in the clinics of the veterinary hospital as we did not observe in all services, nor all potential teachers within an observed service. We also acknowledge the potential that the simple act of having someone observe can alter the dynamics of interaction patterns in the environment. We believe that in those services where we observed more frequently and over longer periods that the effect of the presence of an observer was minimized. Further, the critically important aspect of teaching during rounds was not observed as part of this study. Future studies might focus on the ways that rounds are used as teaching opportunities. Studies on how rounds are used for teaching during clinical training can provide information on how clinical educators take advantage of the more structured teaching opportunities that rounds afford.


  Conclusion Top


We were able to capture a sample capable of informing us of the types of teaching that occur in the clinics of our veterinary teaching hospital. Our results suggest that we are using demonstration and questioning well, but opportunities for advancement in our teaching exist, including allowing the students to learn through supervised practice. We were able to affirm that our students learn from a variety of instructors utilizing different teaching techniques, and there is an opportunity to target training for our instructors on areas that allow a complementary array of teaching styles, rather than a “one-size-fits-all” approach. Similarly, house officers learn primarily from faculty, but fellow house officer lead a significant portion of their learning. This highlights the importance of providing educational training for interns and residents as well as faculty and technicians. As the profession moves toward embracing a Competency-Based Veterinary Education (CBVE) framework and assessing students using an Entrustable Professional Activities (EPA) framework, we will need to give more ownership of patient care to students, so we can help them build the knowledge, skills, and capacities that are associated with day-one practice-ready veterinarians. Given the paucity of these opportunities, in combination with the demands of a busy tertiary-level referral teaching hospital, it is understandable that students may not be trusted to act autonomously. The theoretical framework of cognitive apprenticeship seems to be one that can help guide our professional development activities as we create the learning environments to support CBVE and EPA. While we examine strategies to transition our teaching models, we should appreciate and enhance the excellent teaching that is happening now and plan to invest in all of our teachers as we work to improve veterinary medical education.

Acknowledgments

We would like to acknowledge the contributions of Mr. Ezekiel Michael and Ms. Stephanie O'Brien for their assistance with data collection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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